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Companion Guide: 837 Professional Claims and Encounters Transaction

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Library Reference Number: CLEL10015

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Revision History Document

Version Number

CO Revision Date Revision Page Number(s)

Reason for Revisions Revisions Completed By

Version 1.0 August 2004 All New document. Formerly section 4 of the 837P companion guide. New document contains 837P transaction information only.

Systems/HIPAA Publications

41 August 2004 Changes from CO 41 (20040131)

R Hensley

Version 1.1 198 September 2005 Pages 3-27, 3-34

Updated 2320 SBR09 Comments and 2330B NM109 Guide Description Valid Values and Comments. Also changed the footer date from 20040131 to 20050131.

Systems/ Publications

Version 1.2 303 October 2004 Pages 3-15 through 3-19

Updated 2000B Segment Notes, Comments and Examples relating to the IHCP and HCI claims and payments. (20050131)


Version 1.3 41 December 2004 Pages 3-34, 3-44 to 3-45

Updated 2330B Loop comments for DTP03 and added 2430 Loop DTP segment after CAS segment. (20050131)


Version 1.4 41 January 2005 Section 3 COB updates from CO 41. (20050131)


Version 1.5 352, 42, 43, 55, 57, 49, 36, 58, 340, 39, 353

March 2005 All Changes and updates from COs. (20050131)


Version 1.6 October 2005 All Updating copyright material. Formatting and editing to standard.

Publications

Version 1.7 834 April 2006 Tables First Steps new BSR edit/error codes and descriptions

Publications/ Systems

758 Tables COBA and NPI Version 1.8 789 April 2007 NPI Publications/

Systems


Library Reference Number: CLEL10015 iv [ASC X12N 837 (004010X098) and 004010X098A1 Addenda Revision Date: February 2008 Version 2.1

Document Version Number

CO Revision Date Revision Page Number(s)

Reason for Revisions Revisions Completed By

Version 1.9 1027 July 2007 Tables pages 3-51 and 3-52

July 2007 Publications/ Systems

Version 2.0 789 August 2007 Multiple Revisions for NPI Final Systems/ Publications

Version 2.1 February 2008 Table 3.20 NPI Implementation Publications/ Systems

Revision History Companion Guide: 837 Professional Claims and Encounters Transaction

v Library Reference Number: CLEL10015 [ASC X12N 837 (004010X098) and 004010X098A1 Addenda

Revision Date: February 2008 Version 2.1

Table of Contents Section 1: Introduction .....................................................................................................................1-1 Overview .............................................................................................................................................1-1 837 Professional ..................................................................................................................................1-1 Electronic Voids and Replacements ....................................................................................................1-2 Shadow Claims....................................................................................................................................1-3 Fee-for-Service Claims........................................................................................................................1-3 Section 2: Data Exchange Technical Specifications and Interchange Control Structure ...........2-1 Overview .............................................................................................................................................2-1 Inbound Transactions ..........................................................................................................................2-1 Sample Inbound Interchange Control..................................................................................................2-6 Section 3: Professional Claims and Encounters..............................................................................3-1 Segment Usage – 837 Professional .....................................................................................................3-1 Segment and Data Element Description..............................................................................................3-9 Transaction Examples .......................................................................................................................3-61 Medicaid Primary – No COB............................................................................................................3-61 Medicaid Secondary to Medicare......................................................................................................3-63 Medicaid Tertiary to Medicare and Other Insurer.............................................................................3-64 Medicaid Secondary to Primary Insurer (TPL) .................................................................................3-65 Index................................................................................................................................................... I-1


Library Reference Number: CLEL10015 vi [ASC X12N 837 (004010X098) and 004010X098A1 Addenda Revision Date: February 2008 Version 2.1

Section 1: Introduction

Overview The Indiana Health Coverage Programs (IHCP) has developed technical companion guides to assist application developers during the implementation process. The information contained in the IHCP Companion Guide is intended to supplement the adopted National Electronic Data Interchange Transaction Set Implementation Guide (IG) and provide guidance and clarification as it applies to the IHCP. The IHCP Companion Guide is never intended to modify, contradict, or reinterpret the rules established by the IGs.

The Companion Guide is categorized into three sections:

1. Introduction to the 837 professional

2. Interchange control

3. Transaction specifications

This section, Introduction, provides a general description of the 837 Professional Transaction. Section 2 describes data exchange options and the relevant inbound and outbound interchange control structures. Section 3 contains transaction specific documentation, including segment usage, to assist developers with coding each transaction.

Note: All references to the IHCP provider number included in this Companion Guide refer to the Indiana Health Coverage Program legacy provider number.

837 Professional The ASC X12N 837 (04010X098) transaction is the Health Information Portability and Accountability Act (HIPAA)-mandated instrument by which professional claim or encounter data must be submitted. Any claim that would be submitted on a HCFA/CMS-1500 claim form must be submitted using this transaction if the data is submitted electronically. This includes the following claim types:

• Medical related services

• Medicare Crossover Part B

This companion guide is for the 837 Professional transaction and is not intended to contradict or replace any information in the IG or the IHCP Provider Manual. It is highly recommended that the following resources are available during the development process:

• This document, Companion Guide: 837 Professional Claims and Encounters Transactions

• National Electronic Data Interchange Transaction Set Implementation Guide: Health Care Claim: Professional: 837: ASC X12N 837 (004010X098) and (004010X098A1) Addenda

• IHCP Provider Manual

• First Steps Provider Billing Manual, if applicable.

In addition to compliance checking and the resulting 997 Acknowledgement file, the IHCP creates a Biller Summary Report (BSR) in response to all 837 submissions. This report provides summary


Library Reference Number: CLEL10015 1-1 [ASC X12N 837 (004010X098) and 004010X098A1 Addenda Revision Date: February 2008 Version 2.1

http://www.indianamedicaid.com/ihcp/Publications/manuals.htm

https://www.infirststeps.com/matrix/docs/misc/FirstStepsProviderBillingManualPRFS10001V1.pdf

information about the results of pre-adjudication claim and encounter processing. Information on this report indicates rejected claims not processed by the system. With the full National Provider Identifier (NPI) implementation, the report will also show rejection errors on claims from health care providers where the Billing NPI was not submitted, a submitted NPI has not been reported to the IHCP, or the reported NPI cross-walks to multiple IHCP Legacy Provider Identifiers (LPI).

There are several processing assumptions, limitations, and guidelines a developer must be aware of when implementing the 837P transaction. The following list identifies these processing stipulations:

• With the full implementation of NPI, 837P transactions must be submitted with the NPI for health care providers. Atypical providers may submit with either an NPI or the LPI.

• The IHCP accepts up to 5000 CLM segments per ST – SE. The IG recommends creating this limitation to avert circumstances where file size management may become an issue.

• It is recommended that Patient Loops 2000C and 2010CA are not coded because the IHCP members/subscribers are always the same as the patient. If these loops are present, they do not pass the pre-adjudication edits if the subscriber’s Medicaid ID does not match the patient’s Medicaid ID.

• All monetary amounts have explicit decimals. The decimal point always appears in the character stream if the decimal point is at any place other than the right end. If the value is an integer, decimal point at the right end, the decimal point should be omitted. See the IG for additional clarification.

• Negative quantities or amounts necessary for the adjudication of the claim are rejected.

• All quantities have pre-adjudication edits. Refer to the appropriate segments for IHCP formats.

• Other data elements with lengths greater than IHCP definitions are truncated.

• The IHCP is referred to as IHCP in applicable Receiver segments.

• The IHCP processes a maximum of 50 service lines, or details on the 837P transaction. Claims with details in excess of 50 are rejected by compliance error.

• Coordination of benefits (COB) assumptions: Non-Medicare third party liability (TPL) is only reported at claim level. Medicare paid amounts, deductible, coinsurance, and psych adjustment must be reported at service

line level. Shadow claims:

• Shadow claims are reports of individual patient encounters with an MCO's health care network that contain fee-for-service (FFS)-equivalent detail as to procedures, diagnoses, places of service (POS), billed amounts, and rendering or billing providers. IHCP requires that shadow claims submitted from the MCOs follow the 837 COB format and expect the shadow claim information in the COB Loops of the transaction. Shadow claims are only accepted from MCOs and are rejected from all others.

• MCOs format the 837 with their payment information in the first iteration of the COB Loops prior to submitting to IHCP.

Electronic Voids and Replacements

If the following guidelines are not followed, refer to the BSR for more details.

A Web or electronic data interchange (EDI) replacement request may take up to one business day to process if submitted before 3 p.m. during a normal business day. The primary reason this may occur is that the original claim has already been through a financial.

Section 1: Introduction Companion Guide: 837 Professional Claims and Encounters Transaction

1-2 Library Reference Number: CLEL10015 [ASC X12N 837 (004010X098) and 004010X098A1 Addenda Revision Date: February 2008 Version 2.1

Shadow Claims • The MCO ID, provider ID and the state region must be identical on the replacement as it appears on

the claim that is being replaced.

• The MCO ID, provider ID, state region and recipient information must be identical on a void as it appears on the claim that is being voided.

• The type of claim on the void or replacement must be the same type on the claim being voided or replaced.

• The void or replacement cannot be older than two years from the dates of service on the claim being voided or replaced.

• The void or replacement request must be done against the most recent occurrence of the bill.

• The void or replacement request must be for an IHCP claim that is found in the database.

• A void cannot be processed against a claim that was denied in IndianaAIM.

• A replacement request cannot be performed against a claim that was denied due to a previous void request.

Fee-for-Service Claims • The provider ID, service location, and recipient information must be identical on the void as it

appears on the claim that is being voided.

• If a void is submitted with an NPI, that NPI must cross-walk to the same IHCP LPI and service location that appears on the claim being voided.

• The provider ID and service location information must be identical on the replacement as it appears on the claim that is being replaced.

• If a replacement is submitted with an NPI, that NPI must cross-walk to the same IHCP LPI and service location that appears on the claim being replaced.

• The type of claim on the void or replacement must be the same type on the claim being voided or replaced.

• The replacement cannot be older than one year from the last activity that took place on the claim being replaced.

• The void or replacement request must be done against the most recent occurrence of the bill.

• The void or replacement request must be for an IHCP claim that is found in the database.

• A void cannot be processed against a claim that was denied in IndianaAIM.

• A replacement request cannot be performed against a denied claim due to a previous void request.

Companion Guide: 837 Professional Claims Section 1: Introduction and Encounters Transaction


Section 2: Data Exchange Technical Specifications and Interchange Control

Structure

Overview Appendix A, Section A.1.1 of each National Electronic Data Interchange Transaction Set Implementation Guide (ASC X12N~) (IG), the Health Insurance Portability and Accountability Act (HIPAA), provides details about the rules for ensuring integrity and maintaining the efficiency of data exchange. Data files are transmitted in an electronic envelope. The communication envelope consists of an interchange envelope and functional groups.

The following table defines the use of the inbound 837P control structure as it relates to communication with the Indiana Health Coverage Programs (IHCP).

Inbound Transactions

Table 2.1 – Interchange Control Header

Segment Name Interchange Control Header Segment ID ISA Loop ID N/A Usage Required Segment Notes All positions within each data element in the ISA segment must be filled. Delimiters are

specified in the interchange header segment. The character immediately following the segment ID, ISA, defines the data elements separator. The last character in the segment defines the component element separator, and the segment terminator is the byte that immediately follows the component element separator. The following are examples of the separators.

Character Name Delimiter * Asterisk Data Element Separator : Colon Sub-element Separator ~ Tilde Segment Terminator While it is not required that submitters use these specific delimiters, they are the ones that the IHCP uses for all outbound transactions. Example ISA* 00* ….......* 00*……….* ZZ* P123 ..* ZZ*IHCP……* 930602*

1253* U* 00401* 000000905* 1* P* :~



Table 2.2 – Element ID ISA01-ISA16

Element ID Usage Guide Description and Valid Values Comments ISA01 R Authorization Information Qualifier

00 – No Authorization Information Present

ISA02 R Authorization Information Insert 10 blanks

Always blank. Insert 10 blank spaces.

ISA03 R Security Information Qualifier 00 – No Security Information Present

ISA04 R Security Information Insert 10 blanks

Always blank. Insert 10 blank spaces.

ISA05 R Interchange ID Qualifier ZZ – Mutually Defined

ISA06 R Interchange Sender ID For batch transactions, this is the four-byte sender ID (four to eight characters) assigned by the IHCP. For interactive transactions, this is the eight-byte assigned terminal ID (IN followed by six digits). This field has a required length of 15 bytes; therefore, the field must be blank-filled to the right.

ISA07 R Interchange ID Qualifier ZZ – Mutually Defined

ISA08 R Interchange Receiver ID IHCP

This field has a required length of 15 bytes; therefore, the field must be blank-filled to the right.

ISA09 R Interchange Date Format: YYMMDD. ISA10 R Interchange Time Format: HHMM. ISA11 R Interchange Control Standards Identifier

U – U.S. EDI Community of ASC X12, TDCC, and UCS

ISA12 R Interchange Control Version Number 00401 – Draft Standards for Trial Use Approved for Publication by ASC X12 Procedures Review Board through October 1997

Section 2: Data Exchange Technical Specifications Companion Guide: 837 Professional Claims and Interchange Control Structure and Encounters Transaction


Table 2.2 – Element ID ISA01-ISA16

Element ID Usage Guide Description and Valid Values Comments ISA13 R Interchange Control Number The interchange control number

(ICN) is created by the submitter and must be identical to the associated Interchange Trailer (IEA02). This is a numeric field and must be zero-filled. This number should be unique and the IHCP recommends that it be incremented by one with each ISA segment.

ISA14 R Acknowledgment Requested 0 – No acknowledgment requested 1 – Interchange Acknowledgment Requested

The IHCP always creates an acknowledgment file for each file received.

ISA15 R Usage Indicator P – Production Data T – Test Data

During testing the usage indicator entered must be T. After testing approval, P must be entered for production transactions.

ISA16 R Component Element Separator The component element separator is a delimiter and not a data element. This field provides the delimiter used to separate component data elements within a composite data structure; this value must be different from the data element separator and the segment terminator.

Table 2.3 – Functional Group Header

Segment Name Functional Group Header Segment ID GS Loop ID N/A Usage Required Segment Notes Example GS*HS*P123*IHCP*20020606*105531*5*X*004010X098A1~

Companion Guide: 837 Professional Claims Section 2: Data Exchange Technical Specifications and Encounters Transaction and Interchange Control Structure


Table 2.4 – Element ID GS01-GS08

Element ID Usage Guide Description and Valid Values Comments GS01 R Functional Identifier Code

HC – Health Care Claim (837) Use the appropriate identifier to designate the type of transaction data to follow the GS segment.

GS02 R Application Sender’s Code For batch transactions, this is the four-byte sender ID assigned by the IHCP. For interactive transactions, this is the eight-byte assigned terminal ID (IN followed by six digits).

GS03 R Application Receiver’s Code IHCP

GS04 R Date Format: CCYYMMDD. GS05 R Time Format: HHMMSS GS06 R Group Control Number Assigned number originated and

maintained by the sender. This must match the number in the corresponding GE02 data element on the GE group trailer segment.

GS07 R Responsible Agency Code X – Accredited Standards Committee X12

GS08 R Version/Release/Industry Identifier Code 004010X098A1 – 837P

Use the appropriate identifier to designate the identifier code for the type of transaction data to follow the GS segment. Refer to specific transaction IG for proper value.

Table 2.5 – Functional Group Trailer

Segment Name Functional Group Trailer Segment ID GE Loop ID N/A Usage Required Segment Notes Example GE*1*5~



Table 2.6 – Element ID GE01-GE02

Element ID Usage Guide Description and Valid Values Comments GE01 R Number of Transaction Sets Included Use the number of transaction sets

included in this functional group. GE02 R Group Control Number Group control number GE02 in this

trailer must be identical to the same data element in the associated functional group header, GS06.

Table 2.7 – Interchange Control Trailer

Segment Name Interchange Control Trailer Segment ID IEA Loop ID N/A Usage Required Segment Notes Example IEA*1*000000905~

Table 2.8 – Element ID IEA01-IEA02

Element ID Usage Guide Description and Valid Values Comments IEA01 R Number of Included Functional Groups Use the number of functional groups

included in this interchange envelope. IEA02 R Interchange Control Number Interchange control number IEA02 in

this trailer must be identical to the same data element in the associated interchange control header, ISA13, including padded zeros.

Companion Guide: 837 Professional Claims Section 2: Data Exchange Technical Specifications and Encounters Transaction and Interchange Control Structure


Sample Inbound Interchange Control

Figure 2.1 illustrates a file that includes 270 and 837P transactions. ISA* 00* ..........* 00*……….* ZZ* P123 ..* ZZ*IHCP……* 930602* 1253* U* 00401* 000000905* 1* P* :~

GS*HS*P123*IHCP*20020606*105531*5*X*004010X092A1~

ST – 270 TRANSACTION SET HEADER

DETAIL SEGMENTS

SE – 270 TRANSACTION SET TRAILER

GE*1*5~

GS*HC*P123*IHCP*20020606*105531*5*X*004010X098A1~

ST – 837 TRANSACTION SET HEADER

DETAIL SEGMENTS

SE – 837 TRANSACTION SET TRAILER

GE*1*5~

IEA*2*000000905~

Figure 2.1 – Inbound Interchange Control, 270 and 837P Transactions



Section 3: Professional Claims and Encounters

Segment Usage – 837 Professional The following matrix lists all segments available for submission using the 4010 version of the National Electronic Data Interchange Transaction Set Implementation Guide: Health Care Claim: Professional: 837: ASC X12N 837 (004010X098) and (004010X098A1) Addenda. It includes a Usage column identifying segments that are required (R), situational (S), or not used (N/A) by the Indiana Health Coverage Programs (IHCP). A required segment element must appear on all transactions. Failure to include a required segment results in a compliance error. A situational segment is not required on every type of transaction; however, a situational segment may be required under certain circumstances. Any data in a segment identified in the Usage column with an X is ignored by the IHCP. Any segment identified in the Usage column as required, or situational, is explained in detail in this section. Any element identified as, Not Used by the IHCP, is not required for processing by the IHCP.

Refer to the IHCP Provider Manual for specific billing requirements.

Table 3.1 – 837 Professional, Segment Usage

Segment ID Loop ID Segment Name IHCP Usage R – Required S – Situational X – Not Used

ST N/A Transaction Set Header R BHT N/A Beginning of Hierarchical Transaction R REF N/A Transmission Type Identification R NM1 1000A Submitter Name R N2 1000A Additional Submitter Name Information X – deleted per Addenda PER 1000A Submitter Electronic Data Interchange (EDI)

Contact Information R

NM1 1000B Receiver Name R N2 1000B Receiver Additional Name Information X – deleted per Addenda HL 2000A Billing/Pay-to Hierarchical Level (HL) R PRV 2000A Billing/Pay-to Specialty Information S CUR 2000A Foreign Currency Information X NM1 2010AA Billing Provider Name R N2 2010AA Additional Billing Provider Name Information X – deleted per Addenda N3 2010AA Billing Provider Address R N4 2010AA Billing Provider City/State/ZIP Code R REF 2010AA Billing Provider Secondary Information R REF 2010AA Credit/Debit Card Billing Information X PER 2010AA Billing Provider Contact Information X NM1 2010AB Pay-to Provider Name X



http://www.indianamedicaid.com/ihcp/publications/manuals.htm



N2 2010AB Additional Pay-to-Provider Name Information X – deleted per Addenda N3 2010AB Pay-to Provider Address X N4 2010AB Pay-to Provider City/State/ZIP Code X REF 2010AB Pay-to Provider Secondary Information X HL 2000B Subscriber Hierarchical Level R SBR 2000B Subscriber Information R PAT 2000B Patient Information S NM1 2010BA Subscriber Name R N2 2010BA Additional Subscriber Name Information X – deleted per Addenda N3 2010BA Subscriber Address R N4 2010BA Subscriber City/State/ZIP Code R DMG 2010BA Subscriber Demographic Information R REF 2010BA Subscriber Secondary Information X REF 2010BA Property and Casualty Claim Number X NM1 2010BB Payer Name R N2 2010BB Additional Payer Name Information X – deleted per Addenda N3 2010BB Payer Address X N4 2010BB Payer City/State/ZIP Code X REF 2010BB Payer Secondary Information X NM1 2010BC Responsible Party Name X N2 2010BC Additional Responsible Party Name Information X – deleted per Addenda N3 2010BC Responsible Party Address X N4 2010BC Responsible Party City/State/ZIP Code X NM1 2010BD Credit/Debit Card Holder Name X N2 2010BD Additional Credit/Debit Card Holder Name

Information X – deleted per Addenda

REF 2010BD Credit/Debit Card Information X HL 2000C Patient Hierarchical Level S PAT 2000C Patient Information S NM1 2010CA Patient Name S N2 2010CA Additional Patient Name Information X – deleted per Addenda N3 2010CA Patient Address S N4 2010CA Patient City/State/ZIP Code S DMG 2010CA Patient Demographic Information S

Section 3: Professional Claims and Encounters Companion Guide: 837 Professional Claims and Encounters Transaction




REF 2010CA Patient Secondary Information Number S REF 2010CA Property and Casualty Claim Number S CLM 2300 Claim Information R DTP 2300 Date – Order Date X – deleted per Addenda DTP 2300 Date – Initial Treatment X DTP 2300 Date – Referral Date X – deleted per Addenda DTP 2300 Date – Date Last Seen X DTP 2300 Date – Onset of Current Illness/Symptom X DTP 2300 Date – Acute Manifestation X DTP 2300 Date – Similar Illness/Symptom Onset X DTP 2300 Date – Accident X DTP 2300 Date – Last Menstrual Period (LMP) S DTP 2300 Date – Last X-Ray X DTP 2300 Date – Estimated Date of Birth X – deleted per Addenda DTP 2300 Date – Hearing and Vision Prescription Date X DTP 2300 Date – Disability Begin X DTP 2300 Date – Disability End X DTP 2300 Date – Date Last Worked X DTP 2300 Date – Authorized Return to Work X DTP 2300 Date – Admission S DTP 2300 Date – Date Discharge S DTP 2300 Date – Assumed and Relinquished Care Dates X PWK 2300 Claim Supplemental Information S CN1 2300 Contract Information S AMT 2300 Credit/Debit Card Maximum Amount X AMT 2300 Patient Paid Amount X AMT 2300 Total Purchased Service Amount X REF 2300 Service Authorization Exception Code X REF 2300 Mandatory Medicare (Section 4081) Crossover

Indicator X

REF 2300 Mammography Certification Number X REF 2300 Referral Number – Certification Code S REF 2300 Original Reference Number (Internal Control

Number/Document Control Number - ICN/DCN) S

Companion Guide: 837 Professional Claims Section 3: Professional Claims and Encounters and Encounters Transaction




REF 2300 Prior Authorization S REF 2300 Clinical Laboratory Improvement Amendment

(CLIA) X

REF 2300 Repriced Claim Number X REF 2300 Adjusted Repriced Claim Number X REF 2300 Investigational Device Exemption Number X REF 2300 Claim Identification Number for Clearinghouses

and Other Transmission Intermediaries X

REF 2300 Ambulatory Patient Group (APG) X REF 2300 Medical Record Number S REF 2300 Demonstration Project Identifier X K3 2300 File Information X NTE 2300 Claim Note S CR1 2300 Ambulance Transport Information X CR2 2300 Spine Manipulation Service Information X CRC 2300 Ambulance Certification X CRC 2300 Patient Condition Information: Vision X CRC 2300 Homebound Indicator X CRC 2300 Early and Periodic Screening, Diagnosis, and

Treatment (EPSDT) Referral X – new per Addenda

HI 2300 Health Care Diagnosis Code R HCP 2300 Claim Pricing/Repricing Information X CR7 2305 Home Health Care Plan Delivery X HSD 2305 Health Care Services Delivery X NM1 2310A Referring Provider Name S PRV 2310A Referring Provider Specialty Information X N2 2310A Additional Referring Provider Name Information X – deleted per Addenda REF 2310A Referring Provider Secondary Information S NM1 2310B Rendering Provider Name S PRV 2310B Rendering Provider Specialty Information S N2 2310B Additional Rendering Provider Name Information X – deleted per Addenda REF 2310B Rendering Provider Secondary Information S NM1 2310C Purchased Service Provider Name X REF 2310C Purchased Service Provider Secondary

Information X





NM1 2310D Service Facility Location X N2 2310D Additional Service Facility Location Name


N3 2310D Service Facility Location Address X N4 2310D Service Facility Location City/State/ZIP Code X REF 2310D Service Facility Location Secondary Information X NM1 2310E Supervising Provider Name X N2 2310E Additional Supervising Provider Name


REF 2310E Supervising Provider Secondary Information X SBR 2320 Other Subscriber Information S CAS 2320 Claim Level Adjustment S AMT 2320 Coordination of Benefits (COB) Payer Paid

Amount S

AMT 2320 Coordination of Benefits (COB) Approved Amount

S

AMT 2320 Coordination of Benefits (COB) Allowed Amount S AMT 2320 Coordination of Benefits (COB) Patient

Responsibility Amount X

AMT 2320 Coordination of Benefits (COB) Covered Amount S AMT 2320 Coordination of Benefits (COB) Discount Amount X AMT 2320 Coordination of Benefits (COB) Per Day Limit

Amount X

AMT 2320 Coordination of Benefits (COB) Patient Paid Amount

X

AMT 2320 Coordination of Benefits (COB) Tax Amount X AMT 2320 Coordination of Benefits (COB) Total Claim

Before Taxes Amount X

DMG 2320 Subscriber Demographic Information S OI 2320 Other Insurance Coverage Information X MOA 2320 Medicare Outpatient Adjudication Information X NM1 2330A Other Subscriber Name S N2 2330A Additional Other Subscriber Name Information X – deleted per Addenda N3 2330A Other Subscriber Address S N4 2330A Other Subscriber City/State/ZIP Code S REF 2330A Other Subscriber Secondary Information S





NM1 2330B Other Payer Name S N2 2330B Additional Other Payer Name Information X – deleted per Addenda PER 2330B Other Payer Contact Information X DTP 2330B Claim Adjudication Date S REF 2330B Other Payer Secondary Identifier S REF 2330B Other Payer Prior Authorization or Referral

Number S

REF 2330B Other Payer Claim Adjustment Indicator X NM1 2330C Other Payer Patient Information S REF 2330C Other Payer Patient Identification S NM1 2330D Other Payer Referring Provider S REF 2330D Other Payer Referring Provider Identification S NM1 2330E Other Payer Rendering Provider S REF 2330E Other Payer Rendering Provider Secondary

Identification S

NM1 2330F Other Payer Purchased Service Provider X REF 2330F Other Payer Purchased Service Provider

Identification X

NM1 2330G Other Payer Service Facility Location X REF 2330G Other Payer Service Facility Location

Identification X

NM1 2330H Other Payer Supervising Provider X REF 2330H Other Payer Supervising Provider Identification X LX 2400 Service Line Number R SV1 2400 Professional Service R SV4 2400 Prescription Number X – deleted per Addenda SV5 2400 Durable Medical Equipment (DME) Service X PWK 2400 Durable Medical Equipment Carrier (DMERC)

Certificate of Medical Necessity (CMN) Indicator X

CR1 2400 Ambulance Transport Information X CR2 2400 Spinal Manipulation Service Information X CR3 2400 Durable Medical Equipment (DMERC)

Certification X

CR5 2400 Home Oxygen Therapy Information X CRC 2400 Ambulance Certification X





CRC 2400 Hospice Employee Indicator X CRC 2400 Durable Medical Equipment Carrier (DMERC)

Condition Indicator X

DTP 2400 Date – Service Date R DTP 2400 Date – Certification Revision Date X DTP 2400 Date – Referral Date X – deleted per Addenda DTP 2400 Date – Begin Therapy Date X DTP 2400 Date – Last Certification Date X DTP 2400 Date – Order Date X – deleted per Addenda DTP 2400 Date – Date Last Seen X DTP 2400 Date – Test X DTP 2400 Date – Oxygen Saturation/Arterial Blood Gas Test X DTP 2400 Date – Shipped X DTP 2400 Date – Onset of Current Symptom/Illness X DTP 2400 Date – Last X-ray X DTP 2400 Date – Acute Manifestation X DTP 2400 Date – Initial Treatment X DTP 2400 Date – Similar Illness/Symptom Onset X QTY 2400 Anesthesia Modifying Units X – deleted per Addenda MEA 2400 Test Result X CN1 2400 Contract Information X REF 2400 Repriced Line Item Reference Number X REF 2400 Adjusted Repriced Line Item Reference Number X REF 2400 Prior Authorization (PA) or Referral Number X REF 2400 Line Item Control Number (ICN) S REF 2400 Mammography Certification Number X REF 2400 Clinical Laboratory Improvement Amendment

(CLIA) Information X

REF 2400 Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification

X

REF 2400 Immunization Batch Number X REF 2400 Ambulatory Patient Group (APG) X REF 2400 Oxygen Flow Rate X REF 2400 Universal Product Number (UPN) X AMT 2400 Sales Tax Amount X





AMT 2400 Approved Amount X REF 2400 Prior Authorization (PA) Number S AMT 2400 Postage Claimed Amount X K3 2400 File Information X NTE 2400 Line Note S PS1 2400 Purchased Service Information X HSD 2400 Health Care Services Delivery X HCP 2400 Line Pricing/Repricing Information X LIN 2410 Drug Identification S – new per Addenda CTP 2410 Drug Pricing X – new per Addenda REF 2410 Prescription Number X – new per Addenda NM1 2420A Rendering Provider Name S PRV 2420A Rendering Provider Specialty Information S N2 2420A Additional Rendering Provider Name Information X – deleted per Addenda REF 2420A Rendering Provider Secondary Information S NM1 2420B Purchased Service Provider Name X REF 2420B Purchased Service Provider Secondary

Information X

NM1 2420C Service Facility Location X N2 2420C Additional Service Facility Location Name


N3 2420C Service Facility Location Address X N4 2420C Service Facility Location City/State/ZIP Code X REF 2420C Service Facility Location Secondary Information X NM1 2420D Supervising Provider Name X N2 2420D Additional Supervising Provider Name


REF 2420D Supervising Provider Secondary Information X NM1 2420E Ordering Provider Name X N2 2420E Additional Ordering Provider Name Information X – deleted per Addenda N3 2420E Ordering Provider Address X N4 2420E Ordering Provider City/State/ZIP Code X REF 2420E Ordering Provider Secondary Identification X PER 2420E Ordering Provider Contact Information X NM1 2420F Referring Provider Name X





PRV 2420F Referring Provider Specialty Information X N2 2420F Additional Referring Provider Name Information X – deleted per Addenda REF 2420F Referring Provider Secondary Information X NM1 2420G Other Payer Prior Authorization or Referral

Number S

REF 2420G Other Payer Prior Authorization or Referral Number

S

SVD 2430 Line Adjudication Information S CAS 2430 Line Adjustment S DTP 2430 Line Adjudication Date S LQ 2440 Form Identification Code X FRM 2440 Supporting Documentation X SE N/A Transaction Set Trailer R

Segment and Data Element Description

This section contains tables representing segments required or situational for the Indiana Health Information Portability and Accountability Act (HIPAA) implementation of the 837P. Each segment table contains rows and columns describing different segment elements.

Table 3.2 – Segment and Data Element Description

Segment/Data Element Description Segment Name The industry-assigned segment name identified in the IG. Segment ID The industry-assigned segment ID identified in the IG. Loop ID The loop where the segment should appear. Usage This identifies the segment as required or situational. Segment Notes A brief description of the purpose or use of the segment. Example An example of complete a segment. Element ID The industry-assigned segment ID as identified in the IG. Usage Identifies the data element as R-required, S-situational, or X-not used based on

the IHCP guidelines. Guide Description and Valid Values Industry name associated with the data element. If no industry name exists,

this is the IG data element name. This column also lists in BOLD the values and code sets to use.

Comments Description of the contents of the data elements, including field lengths.



Table 3.3 – Transaction Set Header

Segment Name Transaction Set Header Segment ID ST Loop ID N/A Usage Required Segment Notes This segment begins the transaction. Example: ST*837*7656543~

Table 3.4 – Element ID ST01-ST02

Element ID Usage Guide Description and Valid Values Comments ST01 R Transaction Set Identifier Code

837

ST02 R Transaction Set Control Number This number is assigned locally by the sender and should match the value in the corresponding SE segment.

Table 3.5 – Beginning of Hierarchical Transaction

Segment Name Beginning of Hierarchical Transaction Segment ID BHT Loop ID N/A Usage Required Segment Notes This segment provides the bill date and indicator that determines whether the claim submitted is a

fee-for-service or encounter claim. Example BHT*0019*00*X2FF1*20020901*1230*CH~

Table 3.6 – Element ID BHT01-BHT06

Element ID Usage Guide Description and Valid Values Comments BHT01 R Hierarchical Structure Code

0019 – Information Source

BHT02 R Transaction Set Purpose Code 00 – Original 19 – Reissue

See the IG for specific usage. This field has no affect on the processing the transaction. All transactions are processed as originals.

BHT03 R Originator Application Transaction Identifier This value is assigned by the sender. Not used by the IHCP.



Table 3.6 – Element ID BHT01-BHT06

Element ID Usage Guide Description and Valid Values Comments BHT04 R Transaction Set Creation Date Format: CCYYMMDD

This is the bill date for all claims that follow. For MCOs and crossovers, this is the creation date of the claim files.

BHT05 R Transaction Set Creation Time BHT06 R Claim or Encounter Identifier

CH – Chargeable RP – Reporting

Use CH for fee-for-service (FFS) claims. Use RP for shadow claims/encounters.

Table 3.7 – Transaction Type Identification

Segment Name Transaction Type Identification Segment ID REF Loop ID N/A Usage Required Segment Notes This segment identifies the X12N version and the production versus test status of the transaction. Example REF*87*004010X098A1~

Table 3.8 – Element ID REF01-REF02

Element ID Usage Guide Description and Valid Values Comments REF01 R Reference Identification Qualifier

87 – Functional Category

REF02 R Transmission Type Code 004010X098A1 – Production 004010X098DA1 – Test

This value assumes the 4010 implementation version. Contents of this field must be updated with subsequent version upgrades as they are named.

Table 3.9 – Submitter Name

Segment Name Submitter Name Segment ID NM1 Loop ID 1000A Usage Required Segment Notes This segment identifies the submitter and must include the IHCP-assigned sender ID ETIN. Example NM1*41*2*Clearinghouse Inc.*****46*A23I~



Table 3.10 – Element ID NM101-NM111

Element ID Usage Guide Description and Valid Values Comments NM101 R Entity Identifier Code

41 – Submitter

NM102 R Entity Type Qualifier 1 – Person 2 – Non-Person Entity

NM103 R Submitter Last Name or Organization Name NM105 S Submitter Middle Name NM106 N/A Name Prefix Not used NM107 N/A Name Suffix Not used NM108 R Identification Code Qualifier

46 – ETIN

NM109 R Submitter Identifier Use the sender ID assigned by EDS Electronic Solutions.

NM110 N/A Entity Relationship Code Not used NM111 N/A Entity Identifier Code Not used

Table 3.11 – Submitter EDI Contact Information

Segment Name Submitter EDI Contact Information Segment ID PER Loop ID 1000A Usage Required Segment Notes This segment is required by the IG and must be submitted to be compliant; however, data

submitted is not captured by the IHCP. See the IG for details.

Table 3.12 – Receiver Name

Segment Name Receiver Name Segment ID NM1 Loop ID 1000B Usage Required Segment Notes This segment is required by the IG and must be submitted to be compliant; however, data




Table 3.13 – Billing/Pay-to Provider Hierarchical Level

Segment Name Billing/Pay-to Provider Hierarchical Level Segment ID HL Loop ID 2000A Usage Required Segment Notes This segment and following billing/pay-to provider loops must repeat for every billing provider

submitting claims. Example HL*1**20*1~

Table 3.14 – Element ID HL01-HL04

Element ID Usage Guide Description and Valid Values Comments HL01 R Hierarchical ID Number

1

HL02 N/A Hierarchical Parent ID Number Not used HL03 R Hierarchical Level Code

20 – Information Source

HL04 R Hierarchical Child Code 1

Table 3.15 – Billing/Pay-to Provider Specialty Information

Segment Name Billing/Pay-to Provider Specialty Information Segment ID PRV Loop ID 2000A Usage Situational Segment Notes If the rendering provider is the same as the billing provider, this segment provides the taxonomy

code of the rendering provider for claims requiring taxonomy data. Segment usage changed from Required to Situational per the Addenda.

Example PRV*BI*ZZ*2084P0805X~

Table 3.16 – Element ID PRV01-PRV06

Element ID Usage Guide Description and Valid Values Comments PRV01 R Provider Code

BI – Billing

PRV02 R Reference Identification Qualifier ZZ – Mutually Defined




Element ID Usage Guide Description and Valid Values Comments PRV03 R Provider Taxonomy Code Use the taxonomy code of the billing

provider. PRV04 N/A Not used PRV05 N/A Not used PRV06 N/A Not used

Table 3.17 – Billing Provider Name

Segment Name Billing Provider Name Segment ID NM1 Loop ID 2010AA Usage Required Segment Notes This segment is required by the IG and must be submitted to be compliant. See the IG for details.

This segment contains the National Provider Identifier (NPI) information. If the NPI is used in the NM108/NM109 of this loop, then either the Employer’s Identification Number or the Social Security Number (SSN) of the provider must be carried in the Billing Provider Secondary Identification segment (REF). However, the IHCP will continue to use the Tax ID or SSN on file for the IHCP billing LPI or First Steps LPI and will ignore the Tax ID or SSN submitted. The NPI will be returned on the Biller Summary Report (BSR) and returned for the payee identification on the 835 transaction.

Example Segment with NPI: NM1*85*2*JONES HOSPITAL ****XX*1234567890~

Table 3.18 – Element ID NM101 – NM111


85 – Billing Provider

NM102 R Entity Type Qualifier 1 – Person 2 – Non-Person Entity

NM103 R Name Last or Organization Name NM104 S Name First NM105 S Name Middle NM106 N/A Name Prefix Not used NM107 S Name Suffix Not used



Table 3.18 – Element ID NM101 – NM111

Element ID Usage Guide Description and Valid Values Comments NM108 R Identification Code Qualifier

XX – NPI 24 – Employer’s Identification Number 34 – Social Security Number

XX- NPI required for health care providers. Either the Employer’s Identification Number or the SSN of the provider must be carried in the REF segment in this loop. Atypical, non-health care providers may continue to send either their EIN or SSN

NM109 R Identification Code If XX is sent in NM108, enter the 10-digit NPI. If 24 or 34 is sent, enter the nine digit number


Table 3.19 – Billing Provider Address

Segment Name Billing Provider Address Segment ID N3 Loop ID 2010AA Usage Required Segment Notes This segment is required by the IG and must be submitted to be compliant; however, data


Table 3.20 – Billing Provider City/State/ZIP Code

Segment Name Billing Provider City/State/ZIP Code Segment ID N4 Loop ID 2010AA Usage Required Segment Notes This segment is required by the IG and must be submitted to be compliant. See the IG for details.

This is the Billing Provider’s Service Location City, State, and ZIP Code. The ZIP code entered in N403 is used for the NPI to Legacy Provider Identifier (LPI) crosswalk. Effective May 23, 2008 the crosswalk must successfully identify a unique billing provider in order for the claim to be accepted.

Table 3.21 – Element ID N401-N403

Element ID Usage Guide Description and Valid Values Comments N401 R City Billing Provider’s Service Location City




Element ID Usage Guide Description and Valid Values Comments N402 R State Billing Provider’s Service Location

Two character State N403 R ZIP Code Billing Provider’s Service Location

Nine-digit ZIP Code

Table 3.22 – Billing Provider Secondary Identification

Segment Name Billing Provider Secondary Identification Segment ID REF Loop ID 2010AA Usage Required Segment Notes This segment is used for multiple purposes. The primary usage is to submit the Employer’s

Identification Number or the SSN when XX-NPI is used in the Billing Provider Name segment (NM108-109) of this loop. The IHCP billing provider LPI or First Steps LPI and service location, can be submitted in a repeat of this segment when submitting claims to the IHCP for an atypical provider. Managed care organizations (MCOs) submitting shadow/encounter claims must include their MCO ID and location code in a repeat of this segment. When submitting atypical provider claims to Medicare that are expected to crossover to the IHCP, the IHCP LPI and service location with the 1D qualifier can be included in a repeat of this segment along with submitting the Medicare provider number with the 1C qualifier. Medicare will automatically crossover the claim with both the Medicare and the IHCP provider numbers to the IHCP. Failure to submit the IHCP LPI and service location when submitting to Medicare could result in claim denial by the IHCP. The denied claim may not be reported to the provider if the Medicaid provider number is missing.

Examples Claims submitted by atypical provider to the IHCP or First Steps: REF*1D*100999250A~

Claims containing NPI submitted by provider to the IHCP or First Steps: REF*EI*675438789~

Encounter claims submitted by MCO: REF*B3*2008889902~

Claims submitted by atypical providers to Medicare, expecting to crossover to the IHCP: REF*1C*236450~

REF*1D*100999250A~





1D – Medicaid or First Steps Provider Number B3 – Preferred Provider Organization Number EI – Employer’s Identification Number SY – Social Security Number

B3 is used only by MCOs. EI or SY must be used when the 10-digit NPI is sent in the Billing Provider Name segment of this loop. The tax ID sent must be the number used on the 1099. An additional 2010AA REF segment should be sent with the 1D qualifier and IHCP LPI/service location for atypical providers

REF02 R Billing Provider Additional Identifier When sending the 1D qualifier, use the 10-digit IHCP or First Steps provider number (nine numeric plus one alpha location code). When sending the B3 qualifier, use the MCO ID (nine numeric plus region code). Invalid MCO IDs are rejected and reported on the BSR. When sending the EI qualifier, use the Employer Identification Number used on the 1099. When sending the SY qualifier, use the SSN used on the 1099.

REF03 N/A Description Not used REF04 N/A Reference Identifier Not used

Table 3.24 – Subscriber Hierarchical Level

Segment Name Subscriber Hierarchical Level Segment ID HL Loop ID 2000B Usage Required Segment Notes This segment and following subscriber loops must repeat for every subscriber claim submitted.

This includes claims for IHCP members and HCI. See the IG for additional information about creating HL segments.

Example HL*2*1*22*0~



Table 3.25 – Element ID HL01-HL04

Element ID Usage Guide Description and Valid Values Comments HL01 R Hierarchical ID Number The number increments by one for each

member regardless of program eligibility. HL02 R Hierarchical Parent ID Number This HL segment is always subordinate

to the Billing Pay-to Provider HL. The value in this field must match the Billing/Pay-to Provider Hierarchical ID number.

HL03 R Hierarchical Level Code 22 – Subscriber

HL04 R Hierarchical Child Code 0 – No Subordinate HL Segments in This Hierarchical Structure

Because the member is always the patient, there should be no subordinate HLs to this HL segment.

Table 3.26 – Subscriber Information

Segment Name Subscriber Information Segment ID SBR Loop ID 2000B Usage Required Segment Notes This segment identifies the intended payer of this claim. Valid payers include EDS and HCI. Example SBR*T*18*******MC~

Table 3.27 – Element ID SBR01-SBR09

Element ID Usage Guide Description and Valid Values Comments SBR01 R Payer Responsibility Sequence Number

Code T – Tertiary P – Primary

This data element is not captured by the IHCP for processing; however, it is recommended that submitters use T for Medicaid claims, as the IHCP is traditionally the payer of last resort. For HCI claims, P for Primary payer is recommended.

SBR02 R Patients Relationship to Insured 18 – Self

Not used by the IHCP; however, required for compliance.

SBR03 S Insured Group or Policy Number Not used by the IHCP. SBR04 S Insured Group Name Not used by the IHCP. SBR05 N/A Insurance Type Code Not used SBR06 N/A Coordination of Benefits Code Not used SBR07 N/A Yes/No Condition or Response Code Not used SBR08 N/A Employment Status Code Not used




Element ID Usage Guide Description and Valid Values Comments SBR09 R Claim Filing Indicator Code

MC – Medicaid Not used by IHCP; however, required for compliance.

Table 3.28 – Patient Information

Segment Name Patient Information Segment ID PAT Loop ID 2000B Usage Situational Segment Notes This segment identifies a pregnant IHCP member. When submitting claims to Medicare that are

expected to crossover to the IHCP, identify the pregnant IHCP member. Example PAT********Y~

Table 3.29 – Element ID PAT01-PAT09

Element ID Usage Guide Description and Valid Values Comments PAT01 N/A Individual Relationship Code Not used PAT02 N/A Patient Location Code Not used PAT03 N/A Employment Status Code Not used PAT04 N/A Student Status Code Not used PAT05 S Date/Time Period Format Qualifier Not used by the IHCP PAT06 S Date/Time Period Not used by the IHCP PAT07 S Unit or Basis of Measurement Code Not used by the IHCP PAT08 S Patient Weight Not used by the IHCP PAT09 S Pregnancy Indicator

Y – Yes Use Y if the IHCP member is pregnant.

Table 3.30 – Subscriber Name

Segment Name Subscriber Name Segment ID NM1 Loop ID 2010BA – Subscriber Name Usage Required Segment Notes This segment contains the IHCP or First Steps member name and ID number. For HCI claims, it

contains the recipient’s name and SSN. Example NM1*IL*1*DOE*JOE*X***MI*123456989999~





IL – Insured or Subscriber

NM102 R Entity Type Qualifier 1 – Person

NM103 R Subscriber’s Last Name Use the last name of the IHCP or First Steps member

NM104 R Subscriber’s First Name Use the first name of the IHCP or First Steps member

NM105 S Subscriber’s Middle Initial Not used by the IHCP NM106 N/A Name Prefix Not used NM107 S Subscriber Name Suffix Not used by the IHCP NM108 R Identification Code Qualifier

MI – Member Identification Number ZZ – Mutually Defined

IHCP and First Steps claims are coded with MI. HCI claims are coded with ZZ. Medical review team (MRT)/pre-admission screening resident review (PASRR) claims are coded with ZZ.

NM109 R Subscriber Primary Identifier Use the 12-digit IHCP or First Steps member ID for Medicaid claims. For First Steps claims use the 12-digit First Steps member ID. For HCI claims, use the nine-digit recipient’s SSN. Do not format the SSN with dashes. For MRT/PASRR claims use the 12-digit MRT/PASRR member ID.


Table 3.32 – Subscriber Address

Segment Name Subscriber Address Segment ID N3 Loop ID 2010BA – Subscriber Name Usage Required Segment Notes This segment is required by the IG and must be submitted to be compliant; however, data




Table 3.33 – Subscriber City/State/ZIP Code

Segment Name Subscriber City/State/ZIP Code Segment ID N4 Loop ID 2010BA – Subscriber Name Usage Required Segment Notes This segment is required by the IG and must be submitted to be compliant; however, data


Table 3.34 – Subscriber Demographic Information

Segment Name Subscriber Demographic Information Segment ID DMG Loop ID 2010BA – Subscriber Name Usage Required Segment Notes This segment is required by the IG and must be submitted to be compliant; however, data


Table 3.35 – Payer Name

Segment Name Payer Name Segment ID NM1 Loop ID 2010BB Usage Required Segment Notes This segment identifies EDS as the destination payer for Medicaid claims and HCI for HCI claims. Example NM1*PR*2*EDS*****PI*EDS~



PR – Payer

NM102 R Entity Type Qualifier 2 – Non-Person Entity

NM103 R Payer Name EDS HCI

NM104 N/A Name First Not used NM105 N/A Name Middle Not used NM106 N/A Name Last Not used




Element ID Usage Guide Description and Valid Values Comments NM107 N/A Name Suffix Not used NM108 R Identification Code Qualifier

PI

NM109 R Payer Identifier EDS HCI

Use EDS for IHCP or First Steps claims. Use HCI for HCI claims.


Table 3.37 – Patient Hierarchical Level

Segment Name Patient Hierarchical Level Segment ID HL Loop ID 2000C Usage Situational Segment Notes The IG requires this segment if the 2000C Loop is used and must be submitted to be compliant.

Data submitted is not captured by the IHCP. See the IG for details.

Table 3.38 – Patient Information

Segment Name Patient Information Segment ID PAT Loop ID 2000C – Patient Information Usage Situational Segment Notes The IG requires this segment if the 2000C Loop is used and must be submitted to be compliant.


Table 3.39 – Patient Name

Segment Name Patient Name Segment Name NM1 Loop ID 2010CA – Patient Name Usage Situational Segment Notes The IG requires this segment if the 2000C Loop is used and must be submitted to be compliant. It

is not recommended that a patient loop be coded for the IHCP claims. However, if it is coded, the NM109 of the subscriber must equal the NM109 of the patient or the claim rejects in the pre-adjudication reports.

Example NM1*QC*1*DOE*JOE*X***MI*123456989999~





QC – Patient

NM102 R Entity Type Qualifier 1 – Person

NM103 R Subscriber’s Last Name Not used by the IHCP NM104 R Subscriber’s First Name Not used by the IHCP NM105 S Subscriber’s Middle Initial Not used by the IHCP NM106 N/A Name Prefix Not used NM107 S Subscriber Name Suffix Not used by the IHCP NM108 R Identification Code Qualifier

MI – Member Identification Number ZZ – Mutually Defined

IHCP or First Steps claims are coded with MI. HCI claims are coded with ZZ.

NM109 R Subscriber Primary Identifier If this segment is coded, the 12-digit IHCP member ID or First Steps member ID for of the patient must match the ID submitted in the 2010BA Loop. For HCI claims, use the nine-digit recipient’s SSN. Do not format the SSN with dashes.


Table 3.41 – Patient Address

Segment Name Patient Address Segment ID N3 Loop ID 2010CA – Patient Address Usage Patient Segment Notes The IG requires this segment if the 2010CA Loop is used and must be submitted to be compliant.




Table 3.42 – Patient City/State/ZIP Code

Segment Name Patient City/State/ZIP Code Segment ID N4 Loop ID 2010CA – Patient City/State/ ZIP Code Usage Patient Segment Notes The IG requires this segment if the 2010CA Loop is used and must be submitted to be compliant.


Table 3.43 – Patient Demographic Information

Segment Name Patient Demographic Information Segment ID DMG Loop ID 2010CA – Patient Demographic Information Usage Required Segment Notes The IG requires this segment if the 2010CA Loop is used and must be submitted to be compliant.


Table 3.44 – Claim Information

Segment Name Claim Information Segment ID CLM Loop ID 2300 Usage Required Segment Notes This segment begins the submission of the individual claim information. The IHCP processes a

maximum of 5000 CLM segments per ST-SE. Example CLM*22334E45*325.1***11::1*Y*A*Y*Y**C*AA~

Table 3.45 – Element ID CLM01-CLM20

Element ID Usage Guide Description and Valid Values Comments CLM01 R Patient Account Number Use patient account number of up to 20-

characters. CLM02 R Total Claim Charge Amount Use the sum of all service line or detail,

charges up to 10 byes. The IHCP accepts the maximum HIPAA format of 99999999.99

CLM03 N/A Claim Filing Indicator Code Not used CLM04 N/A Non-Institutional Claim Type Code Not used CLM05 R Health Care Service Location Information This is a composite data element.




Element ID Usage Guide Description and Valid Values Comments CLM05-1 R Facility Type Code Use the two-character place of service

(POS) code. See the IHCP Provider Manual or the First Steps Provider Billing Manual for a list of valid values.

CLM05-2 N/A Facility Code Qualifier Not used CLM05-3 R Claim Frequency Code

1 – Original 7 – Replacement 8 – Void

The IHCP processes all valid values as requested.

CLM06 R Provider Signature Indicator N – No Y – Yes

This data element indicates whether the billing provider signature is on file in the billing office.

CLM07 R Medicare Assignment Code This data element is required by the IG and must be submitted to be compliant; however, data submitted is not captured by the IHCP. See the IG for details.

CLM08 R Benefits Assignment Certification Indicator This data element is required by the IG and must be submitted to be compliant; however, data submitted is not captured by the IHCP. See the IG for details.

CLM09 R Release of Information Code This data element is required by the IG and must be submitted to be compliant; however, data submitted is not captured by the IHCP. See the IG for details.

CLM10 S Patient Signature Source Code Not used by the IHCP CLM11 S Property and Casualty Related Cause Codes This is a composite data element. CLM11-1 R Related Causes Code 1 CLM11-2 S Related Causes Code CLM11-3 S Related Causes Code CLM11-4 S Related Causes Code CLM11-5 S Country Code Not used by the IHCP CLM12 S Special Program Indicator CLM13 N/A Yes/No Condition or Response Code Not used CLM14 N/A Level of Service Code Not used CLM15 N/A Yes/No Condition or Response Code Not used CLM16 S Participation Agreement Not used by the IHCP CLM17 N/A Claim Status Code Not used CLM18 N/A Yes/No Condition or Response Code Not used CLM19 N/A Claim Submission Code Not used








Element ID Usage Guide Description and Valid Values Comments CLM20 S Delay Reason Code Not used by the IHCP

Table 3.46 – Date – Last Menstrual Period

Segment Name Date – Last Menstrual Period Segment ID DTP Loop ID 2300 Usage Situational Segment Notes This segment provides the date of a pregnant woman’s last menstrual period (LMP). Example DTP*484*D8*20021019~

Table 3.47 – Element ID DTP01-DTP03

Element ID Usage Guide Description and Valid Values Comments DTP01 R Date/Time Qualifier

484 – Last Menstrual Period

DTP02 R Date/Time Period Format Qualifier D8 – Date Expressed in Format CCYYMMDD

DTP03 R Last Menstrual Period Date Use the date of the IHCP member’s LMP.

Table 3.48 – Date - Admission

Segment Name Date – Admission Segment ID DTP Loop ID 2300 Usage Situational Segment Notes This segment provides the admission date or the hospitalization From date of service. Example DTP*435*D8*20020727~



435 – Admission




Element ID Usage Guide Description and Valid Values Comments DTP02 R Date/Time Period Format Qualifier

D8 – Date Expressed in Format CCYYMMDD

DTP03 R Related Hospitalization Admission Date Use the date the IHCP member is admitted to the hospital. For example, 20020727 represents an admit date of 7/27/2002.

Table 3.50 – Date - Discharge

Segment Name Date – Discharge Segment ID DTP Loop ID 2300 Usage Situational Segment Notes This segment provides the discharge date or the hospitalization To date of service. Example DTP*096*D8*20020801~



096– Discharge


DTP03 R Related Hospitalization Discharge Date Use the date the IHCP member is discharged from the hospital. For example, 20020801 represents a discharge date of August 1, 2002.

Table 3.52 – Claim Supplemental Information

Segment Name Claim Supplemental Information Segment ID PWK Loop ID 2300 Usage Situational Segment Notes This segment provides additional information required to process the claim, and the information is

mailed to the IHCP. This segment is ignored if BHT06 = RP or if the claim is a Medicare submitted crossover claim.

Example PWK*AS*BM***AC*86576~



Table 3.53 – Element ID PWK01-PWK09

Element ID Usage Guide Description and Valid Values Comments PWK01 R Attachment Report Type Code See the IG for a list of valid values. PWK02 R Attachment Transmission Code

BM – By mail Even though all Attachment Transmission Codes are accepted, claims that suspend for a required attachment can only be resolved by sending the attachment by mail.

PWK03 N/A Report Copies Needed Not used PWK04 N/A Entity Identifier Code Not used PWK05 R Identification Code Qualifier

AC – Attachment Control Number

PWK06 R Attachment Control Number A unique attachment control number of up to 30-characters must be used and must match the number associated with the paper documentation sent by mail. This number is used to link the claim with the paper documentation and must be unique per billing location across all claims.

PWK07 N/A Attachment Description Not used PWK08 N/A Actions Indicated Not used PWK09 N/A Request Category Code Not used

Table 3.54 – Contract Information

Segment Name Contract Information Segment ID CN1 Loop ID 2300 Usage Situational Segment Notes This segment identifies, for MCOs, an encounter from a network provider who has a capitated

payment arrangement with the MCO. The IHCP expects to receive capitation indicator information at the claim level, not the service line level; thus, the Contract Information in the 2400 Loop is not discussed in this companion guide. Do not send this segment unless the provider has a capitated payment arrangement with an MCO.

Example CN1*05~

Table 3.55 – Element ID CN101-CN106

Element ID Usage Guide Description and Valid Values Comments CN101 R Contract Type Code

05 – Capitated A value of 05 indicates the provider has a capitated payment arrangement.

CN102 S Contract Amount Not used by the IHCP



Table 3.55 – Element ID CN101-CN106

Element ID Usage Guide Description and Valid Values Comments CN103 S Contract Percentage Not used by the IHCP CN104 S Contract Code Not used by the IHCP CN105 S Term Discount Percentage Not used by the IHCP CN106 S Contract Version Identifier Not used by the IHCP

Table 3.56 – Referral Number

Segment Name Referral Number Segment ID REF Loop ID 2300 Usage Situational Segment Notes This segment identifies the certification code for a primary medical provider (PMP). The IHCP

expects to receive the certification code at the claim level, not the service line level; thus, the Certification Code information in the 2400 Loop is not discussed in this companion guide. This segment is not used by MCOs.

Example REF*9F*3E~



9F – Referral Number

REF02 R Certification Code Use the two-character PMP certification code.




Table 3.58 – Prior Authorization – First Steps Only

Segment Name Prior Authorization Number Segment ID REF Loop ID 2300 Usage Situational Segment Notes This segment identifies the prior authorization number for First Steps claims only. Prior

Authorization must be entered at either the claim level or the service line level. If entered at the claim level, the prior authorization number will cascade to all details at the service line level that do not have a prior authorization number. If not entered at the claim level, a prior authorization number must be entered for each detail at the service line level.

Example REF*G1*F452365142~



G1 – Prior Authorization Number

REF02 R Prior Authorization Number REF03 N/A Description Not used REF04 N/A Reference Identifier Not used

Table 3.60 – Original Reference Number ICN/DCN

Segment Name Original Reference Number ICN/DCN Segment ID REF Loop ID 2300 Usage Situational Segment Notes This segment is required only if the CLM05-3 Claim Frequency code in the 2300 Loop is a 7 -

Replacement or an 8 - Void. This segment identifies the original IHCP ICN/DCN of the desired claim to be voided or replaced. This is reflected as the original claim on the 835.

Example REF*F8*2004394623999~





F8 – Referral Number

REF02 R Reference Identification – Claim Original Reference Number ICN/DCN

The IHCP ICN of the claim needing to be voided or replaced.


Table 3.62 – Medical Record Number

Segment Name Medical Record Number Segment ID REF Loop ID 2300 Usage Situational Segment Notes The segment submits a medical record number. Example REF*EA*D234345~

Table 363 – Element ID REF01-REF02


EA – Medical Record Number

REF02 R Medical Record Number Use the medical record number for the IHCP member. The IHCP accepts the full HIPAA length of 30 characters. Previously, only the first 20 characters were accepted.

Table 3.64 – Claim Note

Segment Name Claim Note Segment ID NTE Loop ID 2300 Usage Situational Segment Notes The segment provides additional narrative information about the claim. Example NTE*ADD*REQUIRES FEEDING TUBE~



Table 3.65 – Element ID NTE01-NTE02

Element ID Usage Guide Description and Valid Values Comments NTE01 R Note Reference Code See the IG for a list of valid values. NTE02 R Claim Note Text Use up to 80 characters of narrative

description.

Table 3.66 – Health Care Diagnosis Code

Segment Name Health Care Diagnosis Code Segment ID HI Loop ID 2300 Usage Situational Segment Notes This segment identifies all diagnosis codes related to the claim. This segment is required for all

claims submitted to the IHCP. IHCP recognizes all eight possible diagnosis codes. Decimal points in diagnosis codes are implied.

Example HI*BK:V723******BF:4660~

Table 3.67 – Element ID HI01-HI02-7

Element ID Usage Guide Description and Valid Values Comments HI01 R Health Care Code Information This is a composite data element. HI01-1 R Code List Qualifier Code

BK – Principal Diagnosis

HI01-2 R Principal Diagnosis Code Use the appropriate ICD-9 diagnosis code for the principal diagnosis.

HI01-3 N/A Date/Time Period Format Qualifier Not used HI01-4 N/A Date/Time Period Not used HI01-5 N/A Monetary Amount Not used HI01-6 N/A Quantity Not used HI01-7 N/A Version Identifier Not used HI02 S Health Care Code Information This is a composite data element. The

seven data elements in this composite occur seven times in this segment. See the IG for complete details.

HI02-1 R Code List Qualifier Code BF – Diagnosis

HI02-2 R Diagnosis Code Use the appropriate ICD-9 diagnosis code for all other diagnosis codes.

HI02-3 N/A Date/Time Period Format Qualifier Not used HI02-4 N/A Date/Time Period Not used HI02-5 N/A Monetary Amount Not used



Table 3.67 – Element ID HI01-HI02-7

Element ID Usage Guide Description and Valid Values Comments HI02-6 N/A Quantity Not used HI02-7 N/A Version Identifier Not used

Table 3.68 – Referring Provider Name

Segment Name Referring Provider Name Segment ID NM1 Loop ID 2310A Usage Situational Segment Notes This segment provides PMP information on claims when PMP data is required. The IHCP expects

to receive referring provider information at this level, not at the service line level; thus, the referring provider information in the 2420F Loop is not discussed in this companion guide. If the 2310A Loop is being used to provide PMP information, this segment is required by the IG and must be submitted to be compliant. See the IG for details.

Example When submitted with NPI: NM1*DN*1*JONES*JANE****XX*1234567890~.



DN – Referring Provider

NM102 R Entity Type Qualifier 1 - Person 2 – Non-Person Entity

NM103 R Name Last or Organization Name NM104 S Name First NM105 S Name Middle NM106 N/A Name Prefix Not used NM107 S Name Suffix NM108 R Identification Code Qualifier

XX – NPI 24 – Employer Identification Number 34 – Social Security Number

XX – NPI required for covered health care providers.

NM109 R Identification Code If XX is sent in NM108, enter the 10-digit NPI.




Table 3.70 – Referring Provider Secondary Information

Segment Name Referring Provider Secondary Information Segment ID REF Loop ID 2310A Usage Situational Segment Notes This segment contains the IHCP LPI of the PMP, if a non-covered or atypical provider. The

segment can repeat two times; however, only the segment containing the qualifier of 1D is captured.

Example REF*1D*100222999~



1D – Medicaid Provider Number

REF02 R Referring Provider Secondary Identifier Use the nine-digit IHCP LPI for atypical providers.


Table 3.72 – Rendering Provider Name

Segment Name Rendering Provider Name Segment ID NM1 Loop ID 2310B Usage Situational Segment Notes This segment provides rendering provider information on claims when the rendering provider data

is required. If using this loop to provide rendering provider information, this segment is required by the IG and must be submitted to be compliant. See the IG for details. Submission of this loop implies the stated rendering provider information applies to all service lines on the claim unless it is overridden with the rendering provider information in the 2420A Loop. If the NPI is being sent, the NPI will be returned for the rendering provider on the 835 transaction.

Example When submitted with the NPI: NM1*82*1*JONES*JANE****XX*1234567890~. .





82 – Rendering Provider



XX – NPI 24 – Employer Identification Number 34 – Social Security Number

XX – NPI required for health care providers.



Table 3.74 – Rendering Provider Specialty Information

Segment Name Rendering Provider Specialty Information Segment ID PRV Loop ID 2310B Usage Situational Segment Notes This segment provides the taxonomy code of the rendering provider on claims requiring taxonomy

data. Segment usage changed from Required to Situational per the Addenda.

Example PRV*PE*ZZ*404FX0500D~



PE – Performing Always use the provider code of the performing or rendering provider.





Element ID Usage Guide Description and Valid Values Comments PRV03 R Provider Taxonomy Code Use the taxonomy code of the rendering

provider. PRV04 N/A State or Province Code Not used PRV05 N/A Provider Specialty Information Not used PRV06 N/A Provider Organization Code Not used

Table 3.76 – Rendering Provider Secondary Information

Segment Name Rendering Provider Secondary Information Segment ID REF Loop ID 2310B Usage Situational Segment Notes This segment contains the IHCP or First Steps LPI for a non-covered or atypical rendering

provider. The segment can repeat five times; however, only the segment containing the 1D qualifier is captured.

Example REF*1D*100444999C~




REF02 R Rendering Provider Secondary Identifier Use the nine-character IHCP or First Steps LPI of the rendering provider. The service location code is ignored if included.


Table 3.78 – Other Subscriber Information

Segment Name Other Subscriber Information Segment ID SBR Loop ID 2320 Usage Situational Segment Notes The IG requires this segment if the 2320 Loop is used. It must be submitted to be compliant.

IHCP verifies that the Claim Filing Indicator Code correctly represents whether the other insurance carrier for the subscriber is a Medicare payer

Example SBR*S*01*GR00786******OF~




Element ID Usage Guide Description and Valid Values Comments SBR01 R Payer Responsibility Sequence Number Code Not used by IHCP. SBR02 R Individual Relationship Code SBR03 S Reference Identification SBR04 S Name SBR05 N/A Insurance Type Code SBR06 N/A Coordination of Benefits Code SBR07 N/A Yes/No Condition or Response Code SBR08 N/A Employment Status Code SBR09 S Claim Filing Indicator Code The Claim Filing Indicator Code is used

to identify Medicare crossover claims. If the claim is a crossover, the Claim Filing Indicator must be set to MB -Medicare Part B.

Table 3.80 – Claim Level Adjustment

Segment Name Claim Level Adjustment Segment ID CAS Loop ID 2320 Usage Situational Segment Notes Information submitted on the claim level CAS segment is used by the IHCP for utilization

purposes only. All Medicare deductible, coinsurance, and psych adjustment amounts must be submitted on the service line CAS segment for payment by the IHCP. The combination of Adjustment Reason Code, Adjustment Amount, and Adjustment Quantity is reported six times on this segment. The following illustration shows only the first iteration. See the IG for complete details about CAS05-19.

Example CAS*PR*1*153.2~



Table 3.81 – Element ID CAS01-CAS04

Element ID Usage Guide Description and Valid Values Comments CAS01 R Claim Adjustment Group Code CAS02 R Adjustment Reason Code All adjustments and adjustment amounts

are captured by IHCP for claims that were previously adjudicated by another payer for example, MCO, Medicare, or TPL claims.

CAS03 R Adjustment Amount Use the dollar amount associated with the reason code identified in CAS02. IHCP format is 99999999.99

CAS04 S Adjustment Quantity Use the quantity associated with the reason code identified in CAS02. IHCP format is 9999999.999

Table 3.82 – Coordination of Benefits Payer Paid Amount

Segment Name Coordination of Benefits Payer Paid Amount Segment ID AMT Loop ID 2320 Usage Situational Segment Notes This segment reports the amount paid by non-Medicare insurers. Medicare paid amounts should

be submitted at the service line in the SVD segment 2430 Loop. This amount correlates to the payer identified in the NM109 data element of the 2330B Loop.

Example AMT*D*75~

Table 3.83 – Element ID AMT01-AMT03

Element ID Usage Guide Description and Valid Values Comments AMT01 R Amount Qualifier Code

D – Payer Amount Paid

AMT02 R Payer Paid Amount Use the TPL amount paid by the insurer identified in this loop. When the other payer is an MCO, use the MCO paid amount. IHCP format is 99999999.99

AMT03 N/A Credit/Debit Flag Code Not used



Table 3.84 – Coordination of Benefits Approved Amount

Segment Name Coordination of Benefits Approved Amount Segment ID AMT Loop ID 2320 Usage Situational Segment Notes This segment reports the amount approved by the other payer. This amount correlates to the payer

identified in the NM109 data element of the 2330B Loop. Example AMT*AAE*75~



AAE - Approved Amount

AMT02 R Approved Amount IHCP format is 99999999.99 AMT03 N/A Credit/Debit Flag Code Not used

Table 3.86 – Coordination of Benefits Total Allowed Amount

Segment Name Coordination of Benefits Total Allowed Amount Segment ID AMT Loop ID 2320 Usage Situational Segment Notes This segment is used to convey the COB Total Allowed Amount. This amount correlates to the

payer identified in the NM109 data element of the 2330B Loop. Example AMT*B6*85~



B6 – Allowed – Actual

AMT02 R Allowed Amount IHCP format is 99999999.99 AMT03 N/A Credit/Debit Flag Code Not used



Table 3.88 – Coordination of Benefits Covered Amount

Segment Name Coordination of Benefits Covered Amount Segment ID AMT Loop ID 2320 Usage Situational Segment Notes This segment is used to convey the COB Covered Amount. This amount correlates to the payer

identified in the NM109 data element of the 2330B Loop. Example AMT*AU*50~



AU - Coverage Amount

AMT02 R Allowed Amount IHCP format is 99999999.99 AMT03 N/A Credit/Debit Flag Code Not used

Table 3.90 – Other Subscriber Demographic Information

Segment Name Other Subscriber Demographic Information Segment ID DMG Loop ID 2320 Usage Situational Segment Notes Segment contains other payer’s subscriber information. Example DMG*D8*19520201*F~



Table 3.91 – Element ID DMG01-DMG09

Element ID Usage Guide Description and Valid Values Comments DMG01 R Date/Time Period Format Qualifier DMG02 R Other Payer’s Insured Birth Date DMG03 R Other Payer’s Insured Gender Code DMG04 N/A Marital Status Code Not Used DMG05 N/A Race or Ethnicity Code Not Used DMG06 N/A Citizenship Status Code Not Used DMG07 N/A Country Code Not Used DMG08 N/A Basis of Verification Code Not Used DMG09 N/A Quantity Not Used

Table 3.92 – Other Insurance Coverage Information

Segment Name Other Insurance Coverage Information Segment ID OI Loop ID 2320 Usage Required, if the 2320 Loop is used. Segment Notes The IG requires this segment if the 2320 Loop is used. It must be submitted to be compliant;

however, data submitted is not captured by the IHCP. See the IG for details.

Table 3.93 – Other Subscriber Name

Segment Name Other Subscriber Name Segment ID NM1 Loop ID 2330A Usage Required, if 2320 Loop is used. Segment Notes The IG requires this segment if the 2320 Loop is used. See the IG for details. Example NM1*IL*1*DOE*JOE*T***MI*57464~



IL – Insured or Subscriber

NM102 R Entity Type Qualifier Not used by IHCP. NM103 R Other Payer’s Subscriber Name NM104 R Other Payer’s Subscriber First Name




Element ID Usage Guide Description and Valid Values Comments NM105 R Other Payer’s Subscriber Middle Name NM106 N/A Name Prefix Not used NM107 R Other Payer’s Subscriber Name Suffix NM108 R Identification Code Qualifier Not used by IHCP. NM109 R Other Insured Identifier

Table 3.95 – Other Subscriber Address

Segment Name Other Subscriber Address Segment ID N3 Loop ID 2330A Usage Situational Segment Notes This segment specifies information about other subscribers address. See the IG for details. Example N3*4320 WASHINGTON ST SUITE 100~


Element ID Usage Guide Description and Valid Values Comments N301 R Other Payer’s Subscriber Address 1 N302 R Other Payer’s Subscriber Address 2

Table 3.97 – Other Subscriber City/State/ZIP Code

Segment Name Other Subscriber City/State/ZIP Code Segment ID N4 Loop ID 2330A Usage Situational Required when N3 segment is present. Segment Notes This segment specifies information about other subscribers address. See the IG for details. Example N4*PALISADES*OR*23119~


Element ID Usage Guide Description and Valid Values Comments N401 R Other Payer’s Subscriber City N402 R Other Payer’s Subscriber State N403 R Other Payer’s Subscriber ZIP Code N404 R Other Payer’s Subscriber Country Code



Table 3.99 – Other Subscriber Secondary Information

Segment Name Other Subscriber Secondary Information Segment ID REF Loop ID 2330A Usage Situational Segment Notes This segment specifies information about other subscriber’s additional identifiers. See the IG for

details. Example REF*SY*030385074~



IG – Insurance Policy Number SY – Social Security Number

REF02 R Reference Identification Use for the insurance policy number or SSN of the other subscriber.


Table 3.101 – Other Payer Name

Segment Name Other Payer Name Segment ID NM1 Loop ID 2330B Usage Required, if 2320 Loop is used. Segment Notes This segment specifies information about other payers. When submitting claims to Medicare that

are expected to crossover to the IHCP, this segment must be included and contain the payer ID assigned to the IHCP by Medicare. The payer ID representing the IHCP is 70035.

Examples Claims submitted to the IHCP: NM1*PR*2*Family Insurance*****PI*01234~

Claims submitted by provider to Medicare, expecting to crossover to the IHCP: NM1*PR*2*Office Of Medicaid Policy & Planning*****PI*70035~





PR – Payer

NM102 R Entity Type Qualifier 2 – Non-Person Entity

NM103 R Other Payer Organization Name NM104 N/A Name First Not used NM105 N/A Name Middle Not used NM106 N/A Name Prefix Not used NM107 N/A Name Suffix Not used NM108 R Identification Code Qualifier

PI – Payer Identification

NM109 R Other Payer Primary Identifier For crossover claims, the valid payer identifier list can be located at: http://www.indianamedicaid.com/ihcp/Misc_PDF/Medicare_Payer_IDs.pdf When submitting claims to Medicare, that are expected to crossover to the IHCP, use the payer ID for the IHCP – 70035 For shadow claims, the payer identifier should be from this list: 300119960 – Managed Health Services (MHS) 500307680 – MDWise 400752220 – Anthem

For Medicare payments, if the payer is a Medicare payer and the 2320 SBR09 Claim Filing Indicator is MB, the claim is identified as a crossover claim. If the payer is in the Medicare list, but the Claim Filing Indicator does not indicate that the claim is a Medicare crossover claim, the payment is identified as a commercial payment and is summed into TPL. MCO payers are identified by using the NM109 payer ID. Any other payers are identified as TPL.


Table 3.103 – Claim Adjudication Date

Segment Name Claim Adjudication Date Segment ID DTP Loop ID 2330B Usage Situational Segment Notes This segment is required when the Line Adjudication Date is not used and the claim has been

adjudicated. Example DTP*573*D8*19981226~



http://www.indianamedicaid.com/ihcp/Misc_PDF/Medicare_Payer_IDs.pdf

http://www.indianamedicaid.com/ihcp/Misc_PDF/Medicare_Payer_IDs.pdf



573 – Date Claim Paid


DTP03 R Date/Time Period Adjudication or Payment Date MCOs submit payment date.

Table 3.105 – Other Payer Secondary Identification and Reference Number

Segment Name Other Payer Secondary Identification and Reference Number Segment ID REF Loop ID 2330B Usage Situational Segment Notes Utilize segment to send other payer’s claim number. Example REF*F8*465980789~



F8 – Original Reference Number Use F8 to send the other payer’s claim number ICN or DCN. Note: MCO must provide ICN in order to Void or Replace the claim in the future. This encounter claim is reflected on the 835 along with the equivalent IHCP ICN.

REF02 R Reference Identification Use the payer’s ICN or DCN identified in NM109.


Table 3.607 – Other Payer Prior Authorization or Referral Number

Segment Name Other Payer Prior Authorization or Referral Number Segment ID REF Loop ID 2330B Usage Situational Segment Notes This segment specifies information about other payer’s referral or PA number. See the IG for

details.





G1 – Prior Authorization Number 9F – Referral Number

REF02 R Reference Identification Referral Number or PA Number REF03 N/A Description Not used REF04 N/A Reference Identifier Not used

Table 3.629 – Other Payer Referring Provider

Segment Name Other Payer Referring Provider Segment ID NM1 Loop ID 2330D Usage Required, if 2330D Loop is used. Segment Notes This segment specifies information about payer specific provider identification. When submitting

claims to Medicare that are expected to crossover to the IHCP, this segment provides PMP information on claims when PMP data is required. The IHCP expects to receive referring provider information at the claim level, not at the service line level. If using this loop to provide the IHCP PMP information, this segment is required by the IG and must be submitted to be compliant; however, data submitted is not captured by the IHCP. See the IG for details.

Example NM1*DN*1*SUNSET HEALTH CENTER~


Element ID Usage Guide Description and Valid Values Comments NM101 R Entity Identifier Code NM102 R Entity Type Qualifier NM103 R Referring Provider Last or Organization

Name

NM104 N/A NM105 N/A NM106 N/A NM107 N/A NM108 N/A NM109 N/A NM110 N/A NM111 N/A



Table 3.111 – Other Payer Referring Provider ID

Segment Name Other Payer Referring Provider Identification Segment ID REF Loop ID 2330D Usage Situational Segment Notes This segment specifies information about non-destination COB payers’ referring provider

identification numbers. See the IG for details


Element ID Usage Guide Description and Valid Values Comments REF01 R Reference Identification Qualifier REF02 R Reference Identification Other Payer Referring Provider Identifier REF03 N/A Description Not used REF04 N/A Reference Identifier Not used

Table 3.113 – Other Payer Rendering Provider

Segment Name Other Payer Rendering Provider Segment ID NM1 Loop ID 2330E Usage Required, if 2330E Loop is used. Segment Notes When submitting atypical provider claims to Medicare that are expected to crossover to the IHCP,

this segment provides the IHCP rendering provider information on claims when the rendering provider data is required. Submission of this loop implies the stated rendering provider information applies to all service lines on the claim unless it is overridden with the rendering provider information in the 2420A Loop. If using this loop to provide rendering provider information, this segment is required by the IG and must be submitted to be compliant. See the IG for details.

Table 3.114 – Other Payer Rendering Provider ID

Segment Name Other Payer Rendering Secondary Identification Segment ID REF Loop ID 2330E Usage Situational



Table 3.114 – Other Payer Rendering Provider ID

Segment Name Other Payer Rendering Secondary Identification Segment Notes When submitting atypical provider claims to Medicare that are expected to crossover to the IHCP,

this segment provides the IHCP rendering provider information on claims when the rendering provider data is required. The IHCP rendering provider LPI can be submitted with the 1D qualifier in a repeat of this segment in addition to submitting the Medicare provider number with the 1C qualifier. Medicare automatically crossovers the claim with both Medicare and the IHCP provider number to the IHCP. Failure to submit the IHCP rendering provider number could result in the IHCP denying the claim when the rendering provider data is required.

Example Claims submitted for atypical providers to Medicare expecting to crossover to the IHCP: REF*1C*236450~

REF*1D*100222999~


Element ID Usage Guide Description/Valid Values Comments REF01 R Reference Identification Qualifier


REF02 R Other Payer Rendering Provider Secondary Identifier

Use the nine-character IHCP LPI of the rendering provider. The service location code is ignored if included.


Table 3.116 – Service Line

Segment Name Service Line Segment ID LX Loop ID 2400 Usage Required Segment Notes This segment contains the line item number that increments by one for each service line or detail.

The IHCP processes a maximum of 50 LX segments, 2400 Loops, for each CLM segment. Example LX*1~

Table 3.117 – Element ID LX01

Element ID Usage Guide Description and Valid Values Comments LX01 R Assigned Number The first service line should begin with

the number 1. Each subsequent service line/detail should be incremented by one.



Table 3.118 – Professional Service

Segment Name Professional Service Segment ID SV1 Loop ID 2400 Usage Required Segment Notes This segment reports procedure codes, modifiers, charge amounts, and units. The IHCP

recognizes all service lines on a claim. The Total Claim Charge Amount from CLM02 must reflect the totals of all details. Failure to comply, results in compliance rejection.

Example SV1*HC:99396*110*UN*1*23**1:2**Y~

Table 3.119 – Element ID SV101-SV121

Element ID Usage Guide Description and Valid Values Comments SV101 S Composite Medical Procedure Identifier This is a composite data element. SV101-1 R Product/Service ID Qualifier

HC – Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes

HC is the only valid value accepted by the IHCP. Per the addenda, National Drug Code (NDC) information now resides on the LIN/CTP segments in the 2410 Loop.

SV101-2 R Procedure Code Use the five-digit HCPCS procedure code of the service rendered.

SV101-3 S HCPCS Modifier 1 IHCP recognizes all four modifiers. SV101-4 S HCPCS Modifier 2 SV101-5 S HCPCS Modifier 3 SV101-6 S HCPCS Modifier 4 SV101-7 N/A Description Not used SV102 R Line Item Charge Amount IHCP format is 99999999.99 SV103 R Unit or Basis of Measurement Code

F2 – International Unit UN – Units

SV104 R Service Unit Count IHCP format is 9999.99 SV105 S Place of Service Code Required on First Steps claims. SV106 N/A Service Type Code Not used SV107 S Composite Diagnosis Code Pointer This composite element identifies the

diagnosis submitted in the HI segment in the 2300 Loop that is associated with this service line. IHCP recognizes all diagnosis codes. Valid values for this element are 1, 2, 3, 4, 5, 6, 7, and 8.

SV107-1 R Diagnosis Code Pointer



Table 3.119 – Element ID SV101-SV121

Element ID Usage Guide Description and Valid Values Comments SV107-2 R Diagnosis Code Pointer SV107-3 R Diagnosis Code Pointer SV107-4 R Diagnosis Code Pointer SV108 N/A Monetary Amount Not used SV109 R Emergency Indicator

Y – Yes Send Y to denote emergency services. N was removed per addenda.

SV110 N/A Multiple Procedure Code Not used SV111 S EPSDT Indicator Not used by the IHCP SV112 S Family Planning Indicator Not used by the IHCP SV113 N/A Review Code Not used SV114 N/A National or Local Assigned Review Value Not used SV115 S Co-Pay Status Code Not used by the IHCP SV116 N/A Health Care Professional Shortage Area

Code Not used

SV117 N/A Reference Identification Not used SV118 N/A Postal Code Not used SV119 N/A Monetary Amount Not used SV120 N/A Level of Care Code Not used SV121 N/A Provider Agreement Code Not used

Table 3.120 – Date – Service Date

Segment Name Date – Service Date Segment ID DTP Loop ID 2400 Usage Required Segment Notes This segment is used to report the detail To and From dates of service. Example DTP*472*RD8*20021001-20021001~



472 – Service




Element ID Usage Guide Description and Valid Values Comments DTP02 R Date/Time Period Format Qualifier

D8 – Date Expressed in Format CCYYDDMM RD8 – Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

If qualifier D8 is used, the IHCP assumes that the From and Through dates for this service line are the same. The From and Through dates of service should always be the same on First Steps claims.

DTP03 R Service Date

Table 3.122 – Line Item Control Number

Segment Name Line Item Control Number Segment ID REF Loop ID 2400 Usage Situational Segment Notes This segment enables providers to submit unique service line numbers to facilitate the electronic

payment posting. This line item control number is returned on the 835 transaction. See the IG for more specific details.

Example REF*6R*23033838383~



6R – Provider Control Number

REF02 R Line Item Control Number The IHCP accepts up to 30 characters. REF03 N/A Description Not used REF04 N/A Reference Identifier Not used


Segment Name Line Item Control Number Segment ID REF Loop ID 2400 Usage Situational Segment Notes This segment identifies the prior authorization number for First Steps claims only. Prior

Authorization must be entered at either the claim level or the service line level. If entered at the service line level only, it must be entered for each detail. If entered at the claim level, the prior authorization number will cascade to all details at the service line level that do not have a prior authorization level.




Example REF*G1*F452365142~



G1 – Prior Authorization Number

REF02 R Prior Authorization Number REF03 N/A Description Not used REF04 N/A Reference Identifier Not used

Table 3.126 – Line Note

Segment Name Line Note Segment ID NTE Loop ID 2400 Usage Situational Segment Notes The segment provides additional narrative information about this claim. Example NTE*ADD*REQUIRES FEEDING TUBE~

Table 3.127 – Element ID NTE01-NTE02

Element ID Usage Guide Description and Valid Values Comments NTE01 R Note Reference Code See the IG for a list of valid values NTE02 R Claim Note Text Use up to 80 characters of narrative

description.

Table 3.128 – Drug Identification

Segment Name Drug Identification Segment ID LIN Loop ID 2410 Usage Situational



Table 3.128 – Drug Identification

Segment Name Drug Identification Segment Notes If applicable, this segment contains the NDC. LIN04 through LIN31 are listed in this segment but

marked as not used; therefore, they do not appear in this illustration. This newly created segment appears in the Addenda. The NDC field is situational and is required when submitting claims for certain physician administered drugs. When required, the NDC, NDC quantity and NDC units of measure must be billed along with the procedure code. Only the NDC, NDC quantity, and NDC units of measure from the first LIN and CTP segments of each detail are stored. However, providers are allowed to submit up to 25 per detail.

Example LIN**N4*00045012423~

Table 3.129 – Element ID LIN01-LIN03

Element ID Usage Guide Description and Valid Values Comments LIN01 N/A Assigned Identification Not used LIN02 R Product/Service ID Qualifier

N4 – National Drug Code in 5-4-2 format

LIN03 R National Drug Code Use the 11-digit NDC

Table 3.130 – Drug Pricing

Segment Name Drug Pricing Segment ID CTP Loop ID 2410 Usage Situational Segment Notes This segment contains information about the quantity for the NDC listed in the previous LIN

segment. CTP05-2 through CTP05-15 and CTP06 through CTP11 listed in this segment are marked as not used and do not appear in this illustration. This newly created segment appears in the Addenda.

Example CTP**1.2*300*ML~

Table 3.131 – Element ID CTP01-CTP05-15

Element ID Usage Guide Description and Valid Values Comments CTP01 N/A Class of Trade Code Not used CTP02 N/A Price Identifier Code Not used CTP03 R Drug Unit Price Not used by the IHCP CTP04 R National Drug Unit Count Use the quantity associated with the

NDC listed in LIN03. The IHCP format is 9999999.999

CTP05 R Composite Unit of Measure This is a composite data element.



Table 3.131 – Element ID CTP01-CTP05-15

Element ID Usage Guide Description and Valid Values Comments CTP05-1 R Unit or Basis of Measurement Code

GR – Gram ML – Milliliter UN – Unit F2 – International Units

Use the appropriate unit of measure associated with the NDC listed in LIN03.

CTP05-2 N/A Not used CTP05-3 N/A Not used CTP05-4 N/A Not used CTP05-5 N/A Not used CTP05-6 N/A Not used CTP05-7 N/A Not used CTP05-8 N/A Not used CTP05-9 N/A Not used CTP05-10 N/A Not used CTP05-11 N/A Not used CTP05-11 N/A Not used CTP05-12 N/A Not used CTP05-13 N/A Not used CTP05-14 N/A Not used CPT05-15 N/A Not used

Table 3.132 – Rendering Provider Name

Segment Name Rendering Provider Name Segment ID NM1 Loop ID 2420A Usage Situational Segment Notes This segment provides rendering provider information for service lines when rendering provider

data is required. If using this loop to provide rendering provider information, the IG requires this segment. It must be submitted to be compliant. Submitting the data in this loop overrides any rendering provider information previously submitted in the 2310B Loop. If the NPI is being sent the NPI will be returned for the service level rendering provider on the 835 transaction.


Element ID Usage Guide Description and Valid Values Comments





82 – Rendering Provider



XX – NPI 24 – Employer’s Identification Number 34 – Social Security Number

XX – NPI required for health care providers



Table 3.134 – Rendering Provider Specialty Information

Segment Name Rendering Provider Specialty Information Segment ID PRV Loop ID 2420A Usage Situational Segment Notes This segment is used to provide the taxonomy code of the rendering provider on claims where

taxonomy data is required. Segment usage changed from Required to Situational per the Addenda.

Example PRV*PE*ZZ*303BR0900X~



PE – Performing Always use the provider code of the performing provider.





Element ID Usage Guide Description and Valid Values Comments PRV03 R Provider Taxonomy Code Use the rendering provider taxonomy

code. Taxonomy is required on First Steps claims.

PRV04 N/A Not used PRV05 N/A Not used PRV06 N/A Not used

Table 3.136 – Rendering Provider Secondary Information

Segment Name Rendering Provider Secondary Information Segment ID REF Loop ID 2420A Usage Situational Segment Notes This segment contains the IHCP rendering LPI for atypical providers. The segment can repeat five

times, however, only the segment containing the 1D qualifier is captured. Submitting data in this loop overrides the service line rendering provider information previously submitted in the 2310B and 2330E Loop. When submitting atypical provider claims to Medicare that are expected to crossover to the IHCP, the IHCP rendering LPI with qualifier 1D can be submitted in a repeat of this segment in addition to submitting the Medicare provider number with the 1C qualifier. Medicare will automatically crossover the claim with both numbers to the IHCP.

Example REF*1D*212345430~




REF02 R Rendering Provider Secondary Identifier Use the nine-character IHCP or First Steps LPI for the rendering provider. The service location code is ignored if included.



Segment Name Other Payer Prior Authorization or Referral Number Segment ID NM1 Loop ID 2420G




Segment Name Other Payer Prior Authorization or Referral Number Usage Required, if 2320 Loop is used. Segment Notes This segment is used to specify payer specific line level referral or PA numbers. Example NM1*PR*2*Family Insurance*****PI*01234~



PR – Payer

NM102 R Entity Type Qualifier NM103 R Other Payer Organization Name NM104 N/A Name First Not used NM105 N/A Name Middle Not used NM106 N/A Name Prefix Not used NM107 N/A Name Suffix Not used NM108 R Identification Code Qualifier

PI – Payer Identification

NM109 R Other Payer Primary Identifier Must match an Other Payer ID in NM109 of 2330B Loop.





Segment Name Other Payer Prior Authorization or Referral Number Segment ID REF Loop ID 2420G Usage Situational Segment Notes Use when the payer identified in this loop has given a PA or referral number to this claim. This

element is primarily used in payer-to-payer COB situations. Example REF*G1*AB333-Y5~


Element ID Usage Guide Description and Valid Values Comments REF01 R Reference Identification Qualifier REF02 R Reference Identification Other Payer Referral or PA number REF03 N/A Description Not used REF04 N/A Reference Identifier Not used

Table 3.142 – Service Line Adjudication Information

Segment Name Service Line Adjudication Information Segment ID SVD Loop ID 2430 Usage Situational Segment Notes This segment contains the Medicare paid amount detail. This amount is submitted only at the

service line level, not the claim level. Example SVD*00230*345.1*HC:99396~

Table 3.143 – Element ID SVD01-SVD06

Element ID Usage Guide Description and Valid Values Comments SVD-01 R Other Payer Primary Identifier This must match a value submitted in

NM109 in the 2330B Loop. For crossover claims with Medicare payment submitted at the detail, refer to the companion guide values specified for NM109 in Loop 2330B.

SVD02 R Service Line Paid Amount Use the Medicare, MCO, and any other payer paid amount detail. IHCP format is 99999999.99

SVD03 R Composite Medical Procedure Identifier This is a composite data element and is not used by the IHCP.



Table 3.143 – Element ID SVD01-SVD06

Element ID Usage Guide Description and Valid Values Comments SVD03-1 R Product or Service ID Qualifier Not used by the IHCP SVD03-2 R Procedure Code Not used by the IHCP SVD03-3 S Procedure Modifier Not used by the IHCP SVD03-4 S Procedure Modifier Not used by the IHCP SVD03-5 S Procedure Modifier Not used by the IHCP SVD03-6 S Procedure Modifier Not used by the IHCP SVD03-7 S Procedure Code Description Not used by the IHCP SVD04 N/A Product Service ID Not used SVD05 R Paid Service Unit Count Not used by the IHCP SVD06 S Bundled Line Number Not used by the IHCP

Table 3.144 – Service Line Adjustment

Segment Name Service Line Adjustment Segment ID CAS Loop ID 2430 Usage Situational Segment Notes This segment submits Medicare deductible, coinsurance, and psych amounts for Medicare claims.

For non-crossover claims, this segment submits all adjustment amounts. The combination of Adjustment Reason Code, Adjustment Amount, and Adjustment Quantity is reported six times on this segment. The following illustration shows only the first iteration. See the IG for complete details about CAS05-19.

Example CAS*PR*1*66.7**2*25.54~


Element ID Usage Guide Description and Valid Values Comments CAS01 R Claim Adjustment Group Code

PR – Patient Responsibility Medicare deductible, coinsurance, and psych adjustment amounts are always reported with a PR claim adjustment group code for crossover claims.

CAS02 R Adjustment Reason Code Adjustments used in IHCP processing of Medicare claims: 1 – Deductible 2 – Coinsurance 122 – Psych

Only deductible, coinsurance, and psych adjustments are used in IHCP processing of crossover All adjustments and adjustment amounts are captured by IHCP for claims that were previously adjudicated by another payer for example, MCO, Medicare, or TPL claims.




Element ID Usage Guide Description and Valid Values Comments CAS03 R Adjustment Amount Use the dollar amount associated with the

reason code identified in CAS02. IHCP format is 99999999.99

CAS04 S Adjustment Quantity IHCP format is 9999999.999

Table 3.146 – Service Adjudication Date

Segment Name Service Adjudication Date Segment ID DTP Loop ID 2430 Usage Situational Segment Notes This segment is required when the Claim Adjudication Date is not used and the claim has been

adjudicated. Example DTP*573*D8*19981*1226~



573 – Date Claim Paid


DTP03 R Date/Time Period Payment or Adjudication Date MCOs submit payment date.

Table 3.148 – Transaction Set Trailer

Segment Name Transaction Set Trailer Segment ID SE Loop ID N/A Usage Required Segment Notes This segment ends the transaction set. Example SE*32*7656543~

Table 3.149 – Element ID SE01-SE02

Element ID Usage Guide Description and Valid Values Comments



Table 3.149 – Element ID SE01-SE02

Element ID Usage Guide Description and Valid Values Comments SE01 R Transaction Set Identifier Code

Segment Count

SE02 R Transaction Set Control Number This number, assigned locally by the sender, matches the value in the preceding ST segment.

Transaction Examples

Medicaid Primary – No COB

Figure 3.1 illustrates an 837P transaction with Medicaid primary and no COB. ST*837*987654~

BHT*0019*00*X2FF1*20020901*1230*CH~

REF*87*004010X098A1~

NM1*41*2*ANDERSON MEDICAL GROUP*****46*P123~

PER*IC*ALICE WILSON*TE*3174880000~

NM1*40*2*IHCP*****46*IHCP~

HL*1**20*1~

NM1*85*2*ANDERSON MEDICAL GROUP*****XX*1234567890~

N3*4000 E MELROSE STREET~

N4*INDIANAPOLIS*IN*46204~

REF*24*311400511~

HL*2*1*22*0~

SBR*P*18**IHCP*****MC~

NM1*IL*1*DOE*JILL****MI*100444555999~

N3*6000 WEST STREET~


DMG*D8*19590529*M~

NM1*PR*2*EDS*****PI*EDS~

CLM*755555M*126***11::1*Y*A*Y*Y*C*AA:::IN~

DTP*484*D8*20021019~

DTP*435*D8*20021030~

DTP*439*D8*20021030~

DTP*096*D8*20021101~

PWK*AS*BM***AC*86576~

AMT*F5*35~

REF*9F*12~

REF*EA*D234345~

HI*BK:V723*BF:4660~

NM1*DN*1*WILSON*JOEL****34*212222122~



PRV*RF*ZZ*363LP0200X~

REF*1D*100555999D~

LX*1~

SV1*HC:99396*110*UN*1***1:2*1~

DTP*472*RD8*20021030-20021030~

REF*6R*24210~

NM1*82*2*ANDERSON*MARTIN****XX*1123321221~

PRV*PE*ZZ*207RI0001X~

LX*2~

SV1*HC:99000*16*UN*1**1:2*1~

DTP*472*RD8*20021030-20021030~

REF*6R*24211~


PRV*PE*ZZ*207RI0001X~

REF*34*212222122~

SE*46*987654~

Figure 3.1 – 837P Transaction with Medicaid Primary and No COB



Medicaid Secondary to Medicare

Figure 3.2 illustrates an 837P transaction with Medicaid secondary to Medicare. ST*837*987655~

BHT*0019*00*X2FF1*20020901*1230*CH~

REF*87*004010X098A1~



NM1*40*2*IHCP*****46*00120~

HL*1**20*1~




REF*24*363915363~

HL*2*1*22*0~


NM1*IL*1*DOE*JILL****MI*100444555999~



DMG*D8*19590529*M~


CLM*755555M*126***11::1*Y*A*Y*N**EM~

DTP*484*D8*20021019~

DTP*435*D8*20021030~

DTP*096*D8*20021101~


AMT*F5*35~

REF*9F*12~

REF*EA*D234345~

HI*BK:V723*BF:4660~

NM1*DN*1*WILSON*JOEL****34*212222122~

PRV*RF*ZZ*363LP0200X~

REF*1D*100555999D~

SBR*P*18***GP***MB~

DMG*D8*19251014*F~

OI***Y*C**Y~

NM1*IL*1*DOE*JILL****MI*7767654A~

NM1*PR*2*MEDICARE*****PI*00630~

LX*1~

SV1*HC:99396*110*UN*1**1:2*1~

DTP*472*RD8*20021030-20021030~

REF*6R*24210~


PRV*PE*ZZ*456BN0700L~



SVD*00330*65*HC:99396**1~

CAS*PR*2*10~

DTP*573*D8*20021030~

LX*2~

SV1*HC:99000*16*UN*1**1:2*1~

DTP*472*RD8*20021030-20021030~

REF*6R*24211~



SVD*00330*8*HC:99000**1~

CAS*PR*2*2~

DTP*573*D8*20021030~

SE*56*987655~

Figure 3.2 – 837P Transaction with Medicaid Secondary To Medicare

Medicaid Tertiary to Medicare and Other Insurer

Figure 3.3 illustrates an 837P transaction with Medicaid tertiary to Medicare and another insurer. ST*837*987656~

BHT*0019*00*X2FF1*20020901*1230*CH~

REF*87*004010X098A1~



NM1*40*2*IHCP*****46*00120~

HL*1**20*1~




REF*24*351915555~

HL*2*1*22*0~


NM1*IL*1*DOE*JILL****MI*100444555999~



DMG*D8*19590529*M~


CLM*755555M*126***11::1*Y*A*Y*Y*C*EM~

DTP*484*D8*20021019~

DTP*435*D8*20021030~

DTP*096*D8*20021101~


AMT*F5*35~

REF*9F*12~



REF*EA*D234345~

HI*BK:V723*BF:4660~

NM1*DN*1*WILSON*JOEL****34*212222122~

PRV*RF*ZZ*363LP0200N~

REF*1D*100555999D~

SBR*P*18***GP***MB~

DMG*D8*19591014*F~

OI***Y*C**Y~


NM1*PR*2*MEDICARE*****PI*00630~

SBR*P*18***GP***CI~

AMT*D*40~

DMG*D8*19591014*M~

OI***Y*C**Y~


NM1*PR*2*AETNA*****PI*88368~

LX*1~

SV1*HC:99396*110*UN*1**1:2*1~

DTP*472*RD8*20021030-20021030~

REF*6R*24210~



SVD*00630*65*HC:99396**1~

CAS*PR*2*10~

DTP*573*D8*20021030~

LX*2~

SV1*HC:99000*16*UN*1**1:2*1~

DTP*472*RD8*20021030-20021030~

REF*6R*24211~



SVD*88368*8*HC:99000**1~

CAS*PR*2*2~

DTP*573*D8*20021030~

SE*62*987656~

Figure 3.3 – 837P Transaction with Medicaid Tertiary To Medicare and Other Insurer

Medicaid Secondary to Primary Insurer (TPL)

Figure 3.4 illustrates an 837P transaction with Medicaid secondary to a primary insurer. ST*837*987657~

BHT*0019*00*X2FF1*20020901*1230*CH~

REF*87*004010X098A1~





NM1*40*2*IHCP*****46*00120~

HL*1**20*1~




REF*24*333222111~

HL*2*1*22*0~


NM1*IL*1*DOE*JILL****MI*100444555999~



DMG*D8*19590529*M~


CLM*755555M*126***11::1*Y*A*Y*Y*C*EM~

DTP*484*D8*20021019~

DTP*435*D8*20021030~

DTP*096*D8*20021101~


AMT*F5*35~

REF*9F*12~

REF*EA*D234345~

HI*BK:V723*BF:4660~

NM1*DN*1*WILSON*JOEL****34*212222122~

PRV*RF*ZZ*363LP0200N~

REF*1D*100555999D~

SBR*P*18***GP***CI~

AMT*D*40~

DMG*D8*19591014*M~

OI***Y*C**Y~


NM1*PR*2*AETNA*****PI*88368~

LX*1~

SV1*HC:99396*110*UN*1**1:2*1~

DTP*472*RD8*20021030-20021030~

REF*6R*24210~



LX*2~

SV1*HC:99000*16*UN*1**1:2*1~

DTP*472*RD8*20021030-20021030~

REF*6R*24211~





SE*51*987657~

Figure 3.4 – 837P Transaction with Medicaid Secondary To a Primary Insurer



Index

8

837 Professional ..........................................1-1 837P, See 837 Professional .........................1-1

9

997 Acknowledgement................................1-1

B

Beginning of hierarchical transaction........3-10 Biller Summary Report................................1-1 Billing provider

Address ..................................................3-15 City/State/ZIP Code ...............................3-15 Name ......................................................3-14 Secondary identification.........................3-16

Billing/Pay-to provider Hierarchical level ...................................3-13

C

Claim Information.............................................3-24 Note........................................................3-30 Supplemental information ......................3-27

Claim adjudication Date ...............................................3-43, 3-58

Claim level adjustment..............................3-36 COB

Approved amount...................................3-38 Covered amount .....................................3-39 Payer paid amount..................................3-37 Total allowed amount.............................3-38

Companion Guide .......................................1-1 Contract information .................................3-28 Coordination of benefits, See COB ...........3-37

D

Data element description .............................3-9 Data exchange technical specifications .......2-1 Date

Admission ..............................................3-26 Claim adjudication ........................3-43, 3-58 Discharge ...............................................3-27 Last menstrual period.............................3-26 Service date ............................................3-49

Drug identification ....................................3-51 Drug pricing ..............................................3-51

E

Example Medicaid primary-no COB .................... 3-59 Medicaid secondary to Medicare ........... 3-61 Medicaid secondary to primary insurer

(TPL)................................................. 3-64 Medicaid tertiary to Medicare and other 3-62

F

Fee-for-service claims................................. 1-3 Functional group

Header...................................................... 2-3 Trailer ...................................................... 2-4

H

Health care diagnosis code........................ 3-31 Hierarchical level

Billing provider...................................... 3-13 Patient .................................................... 3-22 Pay-to provider ...................................... 3-13 Subscriber .............................................. 3-17

I

Implementation Guide................................. 1-1 Inbound transactions ................................... 2-1 Index ............................................................I-1 IndianaAIM ................................................. 1-2 Information

Claim...................................................... 3-24 Patient ...........................................3-19, 3-22 Subscriber .............................................. 3-18

Interchange control Header...................................................... 2-1 Inbound sample........................................ 2-6 Trailer ...................................................... 2-5

Interchange control structure....................... 2-1 Introduction

Overview.................................................. 1-1

L

Line item control number.......................... 3-50 Line note ................................................... 3-50

M

Medical record number ............................. 3-30


Library Reference Number: CLEL10015 I-1 [ASC X12N 837 (004010X098) and 004010X098A1 Addenda Revision Date: February 2008 Version 2.1

O

Original reference number (ICN/DCN).....3-29 Other insurance

Coverage information.............................3-40 Other payer

Name ......................................................3-42 Prior authorization............... 3-44, 3-55, 3-56 Reference number ..................................3-44 Referral number .................. 3-44, 3-55, 3-56 Referring provider.........................3-45, 3-46 Referring provider ID.............................3-46 Secondary identification.........................3-44

Other subscriber Address ..................................................3-41 City/State/ZIP Code ...............................3-41 Demographic information ......................3-39 Information.............................................3-35 Name ......................................................3-40 Secondary information ...........................3-42

P

Patient Address ..................................................3-23 City/State/ZIP Code ...............................3-24 Demographic information ......................3-24 Hierarchical level ...................................3-22 Information....................................3-19, 3-22 Name ......................................................3-22

Payer Name ......................................................3-21

Prior authorization.....................................3-29 Professional claims and encounters.............3-1 Professional service...................................3-48

R

Receiver Name ......................................................3-12

Referral number.........................................3-29 Referring provider

Name...................................................... 3-32 Secondary information........................... 3-33

Rendering provider Name.............................................3-33, 3-52 Secondary information..................3-35, 3-54 Specialty information...........3-13, 3-34, 3-53

S

Sample Inbound 270 and 837P ............................. 2-6

Segment description.................................... 3-9 Segment usage ............................................ 3-1 Service line................................................ 3-47

Adjudication information....................... 3-56 Adjustment............................................. 3-57

Shadow claims ............................................ 1-3 Submitter

EDI contact information ........................ 3-12 Name...................................................... 3-11

Subscriber Address .................................................. 3-20 City/State/ZIP Code............................... 3-21 Demographic information...................... 3-21 Hierarchical level ................................... 3-17 Information ............................................ 3-18 Name...................................................... 3-19

T

Table of contents........................................... vi Transaction examples................................ 3-59 Transaction set

Header.................................................... 3-10 Trailer .................................................... 3-58

Transaction type Identification.......................................... 3-11

V

Voids and replacements .............................. 1-2

Index Companion Guide: 837 Professional Claims and Encounters Transactions

I-2 Library Reference Number: CLEL10015 [ASC X12N 837 (004010X098) and 004010X098A1 Addenda Revision Date: February 2008 Version 2.1

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